RE-AIM evaluation of the Veterans Health Administration's MOVE! Weight Management Program

A brief online tool to increase behavioral weight loss treatment initiation: Protocol for a cluster randomized trial

BACKGROUND

Comprehensive behavioral weight loss treatments are the first-line approach for obesity in adults. However, only a small portion of eligible individuals will initiate treatment, even when available at low or no cost. To address low uptake, we developed the MyHealthPath Tool, a single-session, online, interactive tool designed to be completed prior to a primary care appointment. MyHealthPath Tool includes questions and automated personalized feedback to increase motivation to initiate a behavioral weight loss treatment.

METHOD/DESIGN

In this cluster randomized controlled trial, primary care practitioners (PCPs; target N = 36) are being recruited from primary care clinics across multiple sites of a single academic-affiliated health care system, then randomized to the MyHealthPath Tool or Control condition. Patients (target N = 828) who have upcoming appointments with enrolled PCPs are recruited prior to their PCP appointment. Patients in both conditions are given information about and free access to two behavioral weight loss treatments. Participants in the MyHealthPath Tool condition also receive the tailored interactive tool and the option to share a summary of their responses with their PCP prior to their appointment. The primary outcome is the initiation of behavioral weight loss treatment within 2 months of the patient's PCP appointment. Secondary outcomes include treatment attendance and weight change over 6 months. Implementation-related outcomes (e.g., indicators of reach) are also being measured.

CONCLUSION

If effective, MyHealthPath could serve as a low-touch method for improving uptake of behavioral weight loss treatment in adults receiving primary care.

Exploring Veteran Mental Health Disparities: A Comparative Analysis of Rural and Urban Communities in the Midwest of the United States

Veterans face unique mental health challenges influenced by their service experiences and post-military transitions into civilian life. Geographic location also plays an integral role in impacting veterans' outcomes and access to proper care. The purpose of this case study is to examine disparities between rural and urban veterans in the Midwest using data collected from the 2022 Behavioral Risk Factor Surveillance System (BRFSS). Self-reported bad mental health days among veterans in rural and urban regions across twelve Midwestern states were analyzed through direct rate estimation and small area estimation techniques utilizing RStudio software. Higher rates of poor mental health days were ultimately observed among urban veterans in most states through both analyses. The results of the direct rate analysis revealed 13.5% of veterans reporting 14 + poor mental health days per month versus 9.5% in rural areas. Likewise, the results of the small area analysis demonstrated 12.2% of veterans reporting 14 + days of poor mental health days per month in urban areas versus 9.8% in rural areas. This highlights the significance of environmental stressors and social determinants of health in differentially impacting mental health outcomes. Thus, tailored interventions utilizing interdisciplinary teams are needed to meet the unique barriers for veterans in different geographic contexts. Despite the cross-sectional nature of the study and reliance on self-reported data, this case study provides valuable insights for mental health disparities among Midwest veterans. Creating a more equitable and accessible mental health landscape for veterans will require targeted and collaborative approaches.

Redefining the Successful Aging of Veterans: A Scoping Review

BACKGROUND AND OBJECTIVES

The aging experiences of military veterans provide critical insights into what successful aging is and means for later life contexts constrained by distinct health and social needs. Can veterans "successfully" age when they are exposed to so many stressors with serious health and social consequences for later life? Veterans can offer valuable lessons for developing comprehensive approaches to refining successful aging, ensuring inclusivity of different older populations. Building on Rowe and Kahn's idea of successful aging, we utilize the complementary concept of "active aging" to explore if there are unique factors, characteristics, and interventions that support active aging in veterans, compared with nonveteran populations.

RESEARCH DESIGN AND METHODS

A rapid review and evidence synthesis was conducted across 9 databases in medicine, psychology, anthropology, sociology, and public health to search for peer-reviewed articles and research reports.

RESULTS

Findings suggest that programs linking health and social dimensions can support the active aging of veterans, namely interventions promoting active physical and cognitive lifestyle as well as social connectedness and engagement. Such programs and interventions help prevent and combat mental and physical health decline and increase quality of life and well-being.

DISCUSSION AND IMPLICATIONS

Findings have implications for veteran and nonveteran populations more broadly, as people can actively age even when they have unique health and social needs.

Real-world impacts from a decade of Quality Enhancement Research Initiative-partnered projects to translate the Diabetes Prevention Program in the Veterans Health Administration

OBJECTIVES

To describe the impacts of four Veterans Health Administration (VA) Quality Enhancement Research Initiative (QUERI) projects implementing an evidence-based lifestyle intervention known as the Diabetes Prevention Program (DPP).

DATA SOURCES AND STUDY SETTING

2012-2024 VA administrative and survey data.

STUDY DESIGN

This is a summary of findings and impacts from four effectiveness-implementation projects focused on in-person and/or online DPP across VA sites.

DATA COLLECTION/EXTRACTION METHODS

Patient demographics, participation data, and key findings and impacts were summarized across reports from the VA Diabetes-Mellitus Quality Enhancement Research Initiative (QUERI-DM) Diabetes Prevention Program (VA DPP) Trial, QUERI-DM Online DPP Trial, the Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) QUERI DPP Project, and EMPOWER 2.0 QUERI Program.

PRINCIPAL FINDINGS

Between 2012 and 2024, four VA QUERI studies enrolled 963 Veterans in DPP across 16 VA sites. All participants had overweight/obesity with one additional risk factor for type 2 diabetes (i.e., prediabetes, elevated risk score, or history of gestational diabetes) and 56% (N = 536) were women. In addition to enhancing the reach of and engagement in diabetes prevention services among Veterans, these projects resulted in three key impacts as follows: (1) informing the national redesign of VA MOVE! including recommendations to increase the number of MOVE! sessions and revise guidelines across 150+ VA sites, (2) enhancing the national evidence base to support online DPP delivery options with citations in national care guidelines outside VA, and (3) demonstrating the importance of gender-tailoring of preventive care services by and for women Veterans to enhance engagement in preventive services.

CONCLUSIONS

Over the past decade, the evolution of VA QUERI DPP projects increased the reach of and engagement in diabetes prevention services among Veterans, including women Veterans who have been harder to engage in lifestyle change programs in VA, and resulted in three key impacts informing type 2 diabetes and obesity prevention efforts within and outside of VA.

Exploring Social Support Dynamics After Bariatric Surgery: Insights From Patients and Providers

INTRODUCTION

Weight loss after bariatric surgery is impacted by several factors, and social support is one of them. Our objective was to characterize patient and provider perceptions about social support after bariatric surgery.

METHODS

We reported a secondary analysis of qualitative data acquired from semi-structured interviews conducted from January-November 2020 with bariatric surgery patients and providers. Participants included primary care providers, health psychologists, registered dietitians, bariatric surgeons, and patients with at least 1 y of follow-up after their bariatric procedure. Interview guides were designed using a hybrid of Andersen's Behavioral Model of Health Services and Torain's Framework for Surgical Disparities. Using directed content analysis, study team members generated codes, which were categorized into themes about social support pertaining to dietary habits, physical activity, and follow-up care.

RESULTS

Forty-five participants were interviewed, including 24 patients (83% female; 79% White; mean age 50.6 ± 10.7 y) and 21 providers (six primary care providers, four health psychologists, five registered dieticians, and six bariatric surgeons). We identified four themes relating to social support affecting weight loss after surgery: (1) family involvement in helping patients adjust to the bariatric diet, (2) engagement in activities with partners/friends, (3) help with transportation to appointments, and (4) life stressors experienced by patients within their social relationships.

CONCLUSIONS

Continued assessment of interpersonal factors after bariatric surgery is essential for weight loss maintenance. Providers can contribute by reinforcing the facilitators of social support and making referrals that may help patients overcome barriers to social support for sustained weight loss after surgery.

Association between a national behavioral weight management program and real-world weight change

OBJECTIVE

In a national cohort of Veterans, weight change was compared between participants in a US Department of Veterans Affairs (VA) behavioral weight management program (MOVE!) and matched non-participants, and between high-intensity and low-intensity participants.

METHODS

Retrospective cohort study of Veterans with 1 + MOVE! visits in 2008-2017 were matched to MOVE! non-participants via sequential stratification. Percent weight change up to two years after MOVE! initiation of participants and non-participants was modeled using generalized additive mixed models, and 1-year weight change of high-intensity or low-intensity participants was also compared.

RESULTS

MOVE! participants (n = 499,696) and non-participant controls (n = 1,336,172) were well-matched, with an average age of 56 years and average BMI of 35. MOVE! participants lost 1.4 % at 12 months and 1.2 % at 24 months, which was 0.89 % points (95 % CI: 0.83-0.96) more at 12 months than non-participants and 0.55 % points (95 % CI: 0.41-0.68) more at 24 months. 9.1 % of MOVE! participants had high-intensity use in one year, and they had 2.38 % point (95 % CI: 2.25-2.52) greater weight loss than low-intensity participation at 12 months (2.8 % vs 0.4 %).

CONCLUSIONS

Participation in VA's system-wide behavioral weight management program (MOVE!) was associated with modest weight loss, suggesting that program modifications are needed to increase Veteran engagement and program effectiveness. Future research should further explore how variations in program delivery and the use of newer anti-obesity medications may impact the program's effectiveness.

Real World Use of Anti-Obesity Medications and Weight Change in Veterans

BACKGROUND

Anti-obesity medications (AOMs) can be initiated in conjunction with participation in the VA national behavioral weight management program, MOVE!, to help achieve clinically meaningful weight loss.

OBJECTIVE

To compare weight change between Veterans who used AOM + MOVE! versus MOVE! alone and examine AOM use, duration, and characteristics associated with longer duration of use.

DESIGN

Retrospective cohort study using VA electronic health records.

PARTICIPANTS

Veterans with overweight or obesity who participated in MOVE! from 2008-2017.

MAIN MEASURES

Weight change from baseline was estimated using marginal structural models up to 24 months after MOVE! initiation. The probability of longer duration of AOM use (≥ 180 days) was estimated via a generalized linear mixed model.

RESULTS

Among MOVE! participants, 8,517 (1.6%) used an AOM within 24 months after MOVE! initiation with a median of 90 days of cumulative supply. AOM + MOVE! users achieved greater weight loss than MOVE! alone users at 6 (3.2% vs. 1.6%, p < 0.001), 12 (3.4% vs. 1.4%, p < 0.001), and 24 months (2.7% vs. 1.5%, p < 0.001), and had a greater probability of achieving ≥ 5% weight loss at 6 (38.8% vs. 26.0%, p < 0.001), 12 (43.1% vs. 28.4%, p < 0.001), and 24 months (40.4% vs. 33.3%, p < 0.001). Veterans were more likely to have ≥ 180 days of supply if they were older, exempt from medication copays, used other medications with significant weight-gain, significant weight-loss, or modest weight-loss side effects, or resided in the West North Central or Pacific regions. Veterans were less likely to have ≥ 180 days of AOM supply if they had diabetes or initiated MOVE! later in the study period.

CONCLUSIONS

AOM use following MOVE! initiation was uncommon, and exposure was time-limited. AOM + MOVE! was associated with a higher probability of achieving clinically significant weight loss than MOVE! alone.

Cost-effectiveness of goal-directed and outcome-based financial incentives for weight loss in low-income populations: the FIReWoRk randomized clinical trial

BACKGROUND

The Financial Incentives for Weight Reduction (FIReWoRk) clinical trial showed that financial incentive weight-loss strategies designed using behavioral economics were more effective than provision of weight-management resources only. We now evaluate cost-effectiveness.

METHODS

Cost-effectiveness analysis of a multisite randomized trial enrolling 668 participants with obesity living in low-income neighborhoods. Participants were randomized to (1) goal-directed incentives (targeting behavioral goals), (2) outcome-based incentives (targeting weight-loss), and (3) resources only, which were provided to all participants and included a 1-year commercial weight-loss program membership, wearable activity monitor, food journal, and digital scale. We assessed program costs, time costs, quality of life, weight, and incremental cost-effectiveness in dollars-per-kilogram lost.

RESULTS

Mean program costs at 12 months, based on weight loss program attendance, physical activity participation, food diary use, self-monitoring of weight, and incentive payments was $1271 in the goal-directed group, $1194 in the outcome-based group, and $834 in the resources-only group (difference, $437 [95% CI, 398 to 462] and $360 [95% CI, 341-363] for goal-directed or outcome-based vs resources-only, respectively; difference, $77 [95% CI, 58-130] for goal-directed vs outcome-based group). Quality of life did not differ significantly between the groups, but weight loss was substantially greater in the incentive groups (difference, 2.34 kg [95% CI, 0.53-4.14] and 1.79 kg [95% CI, -0.14 to 3.72] for goal-directed or outcome-based vs resources only, respectively; difference, 0.54 kg [95% CI, -1.29 to 2.38] for goal-directed vs outcome-based). Cost-effectiveness of incentive strategies based on program costs was $189/kg lost in the goal-directed group (95% CI, $124/kg to $383/kg) and $186/kg lost in the outcome-based group (95% CI, $113/kg to $530/kg).

CONCLUSIONS

Goal-directed and outcome-based financial incentives were cost-effective strategies for helping low-income individuals with obesity lose weight. Their incremental cost per kilogram lost were comparable to other weight loss interventions.

Randomized Controlled Trials to Treat Obesity in Military Populations: A Systematic Review and Meta-Analysis

In recent years, overweight and obesity have reached an alarmingly high incidence and prevalence worldwide; they have also been steadily increasing in military populations. Military personnel, as an occupational group, are often exposed to stressful and harmful environments that represent a risk factor for disordered eating, with major repercussions on both physical and mental health. This study aims to explore the effectiveness of weight loss interventions and assess the significance of current obesity treatments for these populations. Three online databases (PubMed, PsycInfo, and Web of Science) were screened to identify randomized controlled trials (RCTs) aiming to treat obesity in active-duty military personnel and veterans. Random-effects meta-analyses were conducted for body weight (BW) and body mass index (BMI) values, both longitudinally comparing treatment groups from pre-to-post intervention and cross-sectionally comparing the treatment group to controls at the end of the intervention. A total of 21 studies were included: 16 cross-sectional (BW: n = 15; BMI: n = 12) and 16 longitudinal (BW: n = 15; BMI: n = 12) studies were meta-analyzed, and 5 studies were narratively synthesized. A significant small overall BW and BMI reduction from baseline to post-intervention was observed (BW: g = -0.10; p = 0.015; BMI: g = -0.32; p < 0.001), together with a decreased BMI (g = -0.16; p = 0.001) and nominally lower BW (g = -0.08; p = 0.178) in the intervention group compared to controls at the post-intervention time-point. Despite limitations, such as the heterogeneity across the included interventions and the follow-up duration, our findings highlight how current weight loss interventions are effective in terms of BW and BMI reductions in military populations and how a comprehensive approach with multiple therapeutic goals should be taken during the intervention.

Patient and Provider Perceptions About Communication After Bariatric Surgery: A Qualitative Analysis

INTRODUCTION

Communication between patients and providers can strongly influence patient behavior after surgery. The objective of this study was to assess patient and provider perceptions of how communication affected weight-related behaviors after bariatric surgery.

MATERIALS AND METHODS

Semistructured interviews with bariatric surgery patients and providers were conducted from April-November 2020. Patients who had Medicaid within 3 y of surgery were defined as socioeconomically disadvantaged. Interview guides were derived from Andersen's Behavioral Model of Health Services and Torain's Framework for Surgical Disparities. Participants described postoperative experiences regarding diet, physical activity, and follow-up care. A codebook was developed deductively based on the two theories. Directed content analysis identified themes pertaining to patient-provider communication.

RESULTS

Forty-five participants were interviewed, including 24 patients (83% female; 79% White), six primary care providers, four health psychologists, five registered dietitians, and six bariatric surgeons. Four themes regarding communication emerged: (1) Patients experiencing weight regain did not want to follow-up with providers to discuss their weight; (2) Patients from socioeconomically disadvantaged backgrounds had less trust and required more rapport-building from providers to enhance trust; (3) Patients felt that providers did not get to know them personally, which was perceived as a lack of personalized communication; and (4) Providers often changed their language to be simpler, so patients could understand them.

CONCLUSIONS

Patient-provider communication after bariatric surgery is essential, but perceptions about the elements of communication differ between patients and providers. Reassuring patients who have attained less weight loss than expected and establishing trust with socioeconomically vulnerable patients could strengthen care after bariatric surgery.

A very low-carbohydrate diabetes prevention program for veterans with prediabetes: a single-arm mixed methods pilot study

Introduction

All Veterans Affairs (VA) Medical Centers offer the MOVE! Weight Management Program to help patients achieve and maintain a healthy weight through a calorie-restricted, low-fat diet and increased physical activity. Yet, most MOVE! participants do not achieve clinically significant weight loss of ≥5%. A carbohydrate-restricted diet may help more Veterans to achieve ≥5% weight loss.

Methods

This was a single-arm explanatory sequential mixed methods pilot study conducted in one VA health care system. Veterans with prediabetes and body mass index ≥25 kg/m2 were invited to participate in a group-based, virtual, very low-carbohydrate Diabetes Prevention Program (VLC-DPP) consisting of 23 sessions over 12 months. Participants were taught to follow a very low-carbohydrate eating pattern, defined as 20-35 grams of net carbohydrates per day. The primary outcomes were measures of feasibility and acceptability, including program uptake and session attendance. Secondary outcomes included change in weight, hemoglobin A1c, lipids, and patient-reported measures of food cravings, stress eating, perceived health status, and motivation. Interviews were conducted at 6 months to identify factors that facilitated or hindered participants' achievement of ≥5% weight loss.

Results

Among 108 screened Veterans, 21 enrolled in the study (19%), and 18 were included in the analytic cohort. On average, participants attended 12.4/16 weekly sessions and 3.6/8 bimonthly or monthly sessions. At 12 months, mean percent weight loss was 9.4% (SD = 10.7) with 9 participants (50%) achieving ≥5% weight loss. Three factors facilitated achievement of ≥5% weight loss among 10/16 interviewees: (1) enjoyment of low-carbohydrate foods; (2) careful monitoring of carbohydrate intake; and (3) reduced hunger and food cravings. Three factors hindered achievement of ≥5% weight loss among 6/16 interviewees: (1) food cravings, particularly for sweets; (2) challenges with maintaining a food log; and (3) difficulty with meal planning.

Conclusion

A VLC-DPP is feasible and acceptable and shows preliminary efficacy among Veterans with prediabetes. The program's weight loss effectiveness compared to standard MOVE! should be evaluated in a larger-scale trial. Such a program may be offered in addition to the standard MOVE! program to expand the menu of evidence-based lifestyle counseling options for Veterans.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT04881890, identifier NCT04881890.

Socioeconomic disparities and bariatric surgery outcomes: A qualitative analysis

BACKGROUND

Disparities in socioeconomic status (SES) have been associated with less weight loss after bariatric surgery. The objective of this study was to identify socioeconomic barriers to weight loss after bariatric surgery.

METHODS

We performed semi-structured interviews with bariatric surgery patients and providers from April-November 2020. Participants were asked to describe their post-operative experiences regarding dietary habits, physical activity, and follow-up care. Interview data were coded using Directed Content Analysis based on domains in Andersen's Behavioral Model of Health Services Use and Torain's Surgical Disparities Model.

RESULTS

24 patients (median of 4.1 years post-operatively; mean age 50.6 ± 10.7 years; 12 bypass and 12 sleeve; 83% female) and 21 providers (6 bariatric surgeons, 5 registered dietitians, 4 health psychologists, and 6 primary care providers) were interviewed. Barriers to weight loss included: 1) challenging employment situations; 2) limited income; 3) unreliable transportation; 4) unsafe/inconvenient neighborhoods; and 5) limited health literacy.

CONCLUSIONS

Interventions targeting socioeconomic barriers to weight loss are needed to support patients, particularly those who are socioeconomically disadvantaged.

Clinical and Cost Benefits of Anti-Obesity Medication for US Veterans Participating in the MOVE! Weight Management Program

Abstract This study investigated the clinical and economic impact of anti-obesity medications (AOMs; orlistat, liraglutide, phentermine/topiramate extended-release [ER], naltrexone ER/bupropion ER) among United States Veterans with obesity participating in Motivating Overweight/Obese Veterans Everywhere! (MOVE!), a government-initiated weight management program. The study population was identified from electronic medical records of the Veterans Health Administration (2010-2020). Clinical indices of obesity and health care resource utilization and costs were evaluated at 6, 12, and 24 months after the initial dispensing of an AOM in the AOM+MOVE! cohort (N = 3732, mean age 57 years, 79% male) or on the corresponding date of an inpatient or outpatient encounter in the MOVE! cohort (N = 7883, mean age 58 years, 81% male). At 6 months postindex, the AOM+MOVE! cohort had better cardiometabolic indices (eg, systolic blood pressure, diastolic blood pressure, total cholesterol, low-density lipoprotein cholesterol, hemoglobin A1c) than the MOVE! cohort, with the trends persisting at 12 and 24 months. The AOM+MOVE! cohort was significantly more likely than the MOVE! cohort to have weight decreases of 5%-10%, 10%-15%, and >15% and lower body mass index at 6, 12, and 24 months. The AOM+MOVE! cohort also had fewer inpatient and emergency department visits than the MOVE! cohort, which was associated with lower mean total medical costs including inpatient costs. These results suggest that combining AOM treatment with the MOVE! program could yield long-term cost savings for the Veterans Affairs network and meaningful clinical improvements for Veterans with obesity.

Effectiveness of Goal-Directed and Outcome-Based Financial Incentives for Weight Loss in Primary Care Patients With Obesity Living in Socioeconomically Disadvantaged Neighborhoods: A Randomized Clinical Trial

Importance

Financial incentives for weight management may increase use of evidence-based strategies while addressing obesity-related economic disparities in low-income populations.

Objective

To examine the effects of 2 financial incentive strategies developed using behavioral economic theory when added to provision of weight management resources.

Design, Setting, and Participants

Three-group, randomized clinical trial conducted from November 2017 to May 2021 at 3 hospital-based clinics in New York City, New York, and Los Angeles, California. A total of 1280 adults with obesity living in low-income neighborhoods were invited to participate, and 668 were enrolled.

Interventions

Participants were randomly assigned to goal-directed incentives, outcome-based incentives, or a resources-only group. The resources-only group participants were given a 1-year commercial weight-loss program membership, self-monitoring tools (digital scale, food journal, and physical activity monitor), health education, and monthly one-on-one check-in visits. The goal-directed group included resources and linked financial incentives to evidence-based weight-loss behaviors. The outcome-based arm included resources and linked financial incentives to percentage of weight loss. Participants in the incentive groups could earn up to $750.

Main Outcomes and Measures

Proportion of patients achieving 5% or greater weight loss at 6 months.

Results

The mean (SD) age of the 668 participants enrolled was 47.7 (12.4) years; 541 (81.0%) were women, 485 (72.6%) were Hispanic, and 99 (14.8%) were Black. The mean (SD) weight at enrollment was 98.96 (20.54) kg, and the mean body mass index (calculated as weight in kilograms divided by height in meters squared) was 37.95 (6.55). At 6 months, the adjusted proportion of patients who lost at least 5% of baseline weight was 22.1% in the resources-only group, 39.0% in the goal-directed group, and 49.1% in the outcome-based incentive group (difference, 10.08 percentage points [95% CI, 1.31-18.85] for outcome based vs goal directed; difference, 27.03 percentage points [95% CI, 18.20-35.86] and 16.95 percentage points [95% CI, 8.18-25.72] for outcome based or goal directed vs resources only, respectively). However, mean percentage of weight loss was similar in the incentive arms. Mean earned incentives was $440.44 in the goal-directed group and $303.56 in the outcome-based group, but incentives did not improve financial well-being.

Conclusions and Relevance

In this randomized clinical trial, outcome-based and goal-directed financial incentives were similarly effective, and both strategies were more effective than providing resources only for clinically significant weight loss in low-income populations with obesity. Future studies should evaluate cost-effectiveness and long-term outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT03157713.

Facility-level program components leading to population impact: a coincidence analysis of obesity treatment options within the Veterans Health Administration

Obesity is a well-established risk factor for increased morbidity and mortality. Comprehensive lifestyle interventions, pharmacotherapy, and bariatric surgery are three effective treatment approaches for obesity. The Veterans Health Administration (VHA) offers all three domains but in different configurations across medical facilities. Study aim was to explore the relationship between configurations of three types of obesity treatments, context, and population impact across VHA using coincidence analysis. This was a cross-sectional analysis of survey data describing weight management treatment components linked with administrative data to compute population impact for each facility. Coincidence analysis was used to identify combinations of treatment components that led to higher population impact. Facilities with higher impact were in the top two quintiles for (1) reach to eligible patients and (2) weight outcomes. Sixty-nine facilities were included in the analyses. The final model explained 88% (29/33) of the higher-impact facilities with 91% consistency (29/32) and was comprised of five distinct pathways. Each of the five pathways depended on facility complexity-level plus factors from one or more of the three domains of weight management: comprehensive lifestyle interventions, pharmacotherapy, and/or bariatric surgery. Three pathways include components from multiple treatment domains. Combinations of conditions formed "recipes" that lead to higher population impact. Our coincidence analyses highlighted both the importance of local context and how combinations of specific conditions consistently and uniquely distinguished higher impact facilities from lower impact facilities for weight management.

Table for two: Perceptions of social support from participants in a weight management intervention for veterans with PTSD and overweight or obesity

Individuals with posttraumatic stress disorder (PTSD) are at an increased risk of being classified as overweight or with obesity in part due to PTSD symptoms (e.g., sleep disturbance and social isolation) interfering with activity and healthy eating. MOVE!+UP is a 16-week behavioral weight management program, tailored to address such barriers for people with PTSD, by combining evidence-based weight loss education and support with cognitive behavior therapy skills to reduce PTSD symptom-based weight management barriers. This qualitative study examined veterans' (n = 37) perceptions of social support relevant to weight management, health behaviors, and mental health while participating in an uncontrolled pilot of MOVE!+UP. Template analysis of transcripts from 1-hr semistructured qualitative interviews identified four main categories of participant responses. Participants described positive aspects, particularly cohesiveness around a shared veteran identity, feeling less alone, accountability, and having others eat healthier and exercise with them. Conversely, relationship-based barriers included other participants' poor MOVE!+UP group session attendance and engagement, and loved ones' encouragement of making unhealthy choices. Many described having limited relationships or trouble accessing available support. Finally, PTSD symptoms were a significant barrier to utilizing social support to facilitate weight loss. Findings suggest future behavioral weight management programs should recruit members with similar backgrounds to capitalize on shared experience, encourage consistent attendance and meaningful participation, deliver education about how to leverage social support from others outside the program, and address mental health symptoms that impede social support and healthy lifestyles. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Engaging primary care patients with existing online tools for weight loss: A pilot trial

Objective

Free online tools show potential for promoting weight loss at a low cost, but there is limited evidence about how to effectively engage patients with them. To address this, a low-dose, flexible intervention was developed that aims to enhance weight-related discussions with primary care providers (PCPs) and engage patients with an organic (i.e., not researcher-created) weight loss-focused social media community and online self-monitoring tool. Feasibility and acceptability of the intervention was evaluated in a single-arm, 12-week pilot.

Methods

PCPs were recruited at two clinics, then PCP's patients with upcoming appointments were identified and recruited. Patients received an interactive online kickoff before their scheduled primary care appointment, then 8 follow-up messages over 12 weeks via email or their electronic health record patient portal. Patients completed assessments at baseline, post-appointment, and week 12. Primary care providers and patients completed semi-structured interviews.

Results

All PCPs approached enrolled (n = 6); patient recruitment was on track to meet the study goal prior to COVID-19 restrictions, and n = 27 patients enrolled. Patient satisfaction with the pre-appointment kickoff was high. Twenty-four patients reported discussing weight-related topics at their primary care appointment and all were satisfied with the discussion. Twenty-two patients completed 12-week assessments. Of these, 15 reported engaging with the self-monitoring tool and 9 with the social media community. Patient interviews revealed reasons for low social media community engagement, including perceived lack of fit. On average, patients with available data (n = 21) lost 2.4 ± 4.1% of baseline weight, and 28.6% of these patients lost ≥3% of baseline weight. Primary care providers reported high intervention satisfaction.

Conclusions

The intervention and trial design show potential, although additional strategies are needed to promote tool engagement.

Implementation of the spinal cord injury exercise guidelines in the hospital and community settings: Protocol for a type II hybrid trial

STUDY DESIGN

Type II hybrid effectiveness-implementation trial protocol.

OBJECTIVES

To (1) evaluate the implementation of coordinated physical activity (PA) coaching delivered by physiotherapists and spinal cord injury (SCI) peers during the transition from in-hospital care to living in a community (implementation objective) and (2) assess the effect of coaching on PA behaviour and psychosocial predictors among people with SCI (effectiveness objective).

SETTING

Rehabilitation hospital and home/community settings in British Columbia, Canada.

METHODS

Implementation objective: PA coaches (physiotherapists and SCI peers) receive an implementation intervention including training, monitoring, feedback, and champion support. A Theoretical Domains Framework-based questionnaire is collected at baseline, post-training, 2, and 6 months follow-up and semi-structured interviews conducted at 6 months. Effectiveness objective: Using a quasi-experimental design, 55 adults with SCI are allocated to intervention (PA coaching, n = 30) or control (usual care, n = 25) groups. Participants in the intervention group are referred by physiotherapists to receive 11 SCI peer-delivered PA coaching sessions in the community. Control participants received usual care. Questionnaires assessing PA behaviour and psychosocial predictors are administered at baseline, 2-months, 6-months, and 1-year. Semi-structured interviews are conducted to assess intervention satisfaction at 6 months. Analyses include one-way (implementation objective) and two-way (effectiveness objective) repeated measures ANCOVAs for questionnaire-reported outcomes and thematic content analysis for interview data. Data are summarised using the reach effectiveness adoption implementation maintenance (RE-AIM) framework.

ETHICS AND DISSEMINATION

The University of British Columbia Clinical Research Ethics Board approved the protocol (#H19-02694), clinicaltrials.gov registration NCT04493606. Documentation of the adoption process will inform implementation in future sites.

Adoption and Appropriateness of mHealth for Weight Management in the Real World: A Qualitative Investigation of Patient Perspectives

Background

Mobile health (mHealth) interventions for weight management can result in weight loss outcomes comparable to in-person treatments. However, there is little information on implementing these treatments in real-world settings.

Objective

This work aimed to answer two implementation research questions related to mHealth for weight management: (1) what are barriers and facilitators to mHealth adoption (initial use) and engagement (continued use)? and (2) what are patient beliefs about the appropriateness (ie, perceived fit, relevance, or compatibility) of mHealth for weight management?

Methods

We conducted semistructured interviews with patients with obesity at a single facility in an integrated health care system (the Veterans Health Administration). All participants had been referred to a new mHealth program, which included access to a live coach. We performed a rapid qualitative analysis of interviews to identify themes related to the adoption of, engagement with, and appropriateness of mHealth for weight management.

Results

We interviewed 24 veterans, seven of whom used the mHealth program. Almost all participants were ≥45 years of age and two-thirds were White. Rapid analysis identified three themes: (1) coaching both facilitates and prevents mHealth adoption and engagement by promoting accountability but leading to guilt among those not meeting goals; (2) preferences regarding the mode of treatment delivery, usability, and treatment content were barriers to mHealth appropriateness and adoption, including preferences for in-person care and a dislike of self-monitoring; and (3) a single invitation was not sufficient to facilitate adoption of a new mHealth program. Themes were unrelated to participants’ age, race, or ethnicity.

Conclusions

In a study assessing real-world use of mHealth in a group of middle-aged and older adults, we found that—despite free access to mHealth with a live coach—most did not complete the registration process. Our findings suggest that implementing mHealth for weight management requires more than one information session. Findings also suggest that focusing on the coaching relationship and how users’ lives and goals change over time may be an important way to facilitate engagement and improved health. Most participants thought mHealth was appropriate for weight management, with some nevertheless preferring in-person care. Therefore, the best way to guarantee equitable care will be to ensure multiple routes to achieving the same behavioral health goals. Veterans Health Administration patients have the option of using mHealth for weight management, but can also attend group weight management programs or single-session nutrition classes or access fitness facilities. Health care policy does not allow such access for most people in the United States; however, expanded access to behavioral weight management is an important long-term goal to ensure health for all.

Facility-level conditions leading to higher reach: a configurational analysis of national VA weight management programming

Background

While the Veterans Health Administration (VHA) MOVE! weight management program is effective in helping patients lose weight and is available at every VHA medical center across the United States, reaching patients to engage them in treatment remains a challenge. Facility-based MOVE! programs vary in structures, processes of programming, and levels of reach, with no single factor explaining variation in reach. Configurational analysis, based on Boolean algebra and set theory, represents a mathematical approach to data analysis well-suited for discerning how conditions interact and identifying multiple pathways leading to the same outcome. We applied configurational analysis to identify facility-level obesity treatment program arrangements that directly linked to higher reach.

Methods

A national survey was fielded in March 2017 to elicit information about more than 75 different components of obesity treatment programming in all VHA medical centers. This survey data was linked to reach scores available through administrative data. Reach scores were calculated by dividing the total number of Veterans who are candidates for obesity treatment by the number of “new” MOVE! visits in 2017 for each program and then multiplied by 1000. Programs with the top 40 % highest reach scores (n = 51) were compared to those in the lowest 40 % (n = 51). Configurational analysis was applied to identify specific combinations of conditions linked to reach rates.

Results

One hundred twenty-seven MOVE! program representatives responded to the survey and had complete reach data. The final solution consisted of 5 distinct pathways comprising combinations of program components related to pharmacotherapy, bariatric surgery, and comprehensive lifestyle intervention; 3 of the 5 pathways depended on the size/complexity of medical center. The 5 pathways explained 78 % (40/51) of the facilities in the higher-reach group with 85 % consistency (40/47).

Conclusions

Specific combinations of facility-level conditions identified through configurational analysis uniquely distinguished facilities with higher reach from those with lower reach. Solutions demonstrated the importance of how local context plus specific program components linked together to account for a key implementation outcome. These findings will guide system recommendations about optimal program structures to maximize reach to patients who would benefit from obesity treatment such as the MOVE! program.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06774-w.

Testing a tailored weight management program for veterans with PTSD: The MOVE! + UP randomized controlled trial

Post-traumatic stress disorder (PTSD), prevalent among Veterans, increases risk for having a high Body Mass Index. Although the Veterans Health Administration (VHA) offers an evidence-based behavioral weight management program called MOVE!, participants with PTSD lose less weight than those without mental health conditions, despite comparable participation. PTSD symptoms can interfere with one's ability to be physically active and maintain a healthy diet, the key targets in weight management programs. We developed and piloted a behavioral weight management program called MOVE! + UP that targets PTSD-related weight loss barriers. MOVE! + UP includes 16 group sessions with training in evidence-based weight management strategies, coupled with Cognitive Behavior Therapy (CBT) skills to address PTSD-specific barriers. The 16 sessions also include 30-min community walks to address PTSD-related barriers that may impede exercise. Two individual dietician sessions are provided. This hybrid type 1 randomized controlled trial (RCT) will compare MOVE! + UP to standard care-MOVE!-among 164 Veterans with BMI ≥ 25 who are receiving care for PTSD. We will randomize participants to MOVE! + UP or standard care and will compare absolute post-baseline change in weight at 6 (primary outcome) and 12 (secondary outcome) months, and PTSD symptom severity at 6 and 12 months (secondary outcome). Exploratory analyses will compare the treatment conditions on treatment targets measured at 6 months (e.g., physical activity, eating behavior, social support). Finally, we will estimate intervention costs, and identify MOVE! + UP implementation barriers and facilitators. If effective, MOVE! + UP could be an efficient way to simultaneously address physical and mental health for Veterans with PTSD.

The Relationship Between Body Mass Index and Pain Intensity Among Veterans with Musculoskeletal Disorders: Findings from the MSD Cohort Study

OBJECTIVE

To examine the relationship between body mass index (BMI) and pain intensity among veterans with musculoskeletal disorder diagnoses (MSDs; nontraumatic joint disorder; osteoarthritis; low back, back, and neck pain).

SETTING

Administrative and electronic health record data from the Veterans Health Administration (VHA).

SUBJECTS

A national cohort of US military veterans with MSDs in VHA care during 2001-2012 (N = 1,759,338).

METHODS

These cross-sectional data were analyzed using hurdle negative binomial models of pain intensity as a function of BMI, adjusted for comorbidities and demographics.

RESULTS

The sample had a mean age of 59.4, 95% were male, 77% were white/Non-Hispanic, 79% were overweight or obese, and 42% reported no pain at index MSD diagnosis. Overall, there was a J-shaped relationship between BMI and pain (nadir = 27 kg/m2), with the severely obese (BMI ≥ 40 kg/m2) being most likely to report any pain (OR vs normal weight = 1.23, 95% confidence interval = 1.21-1.26). The association between BMI and pain varied by MSD, with a stronger relationship in the osteoarthritis group and a less pronounced relationship in the back and low back pain groups.

CONCLUSIONS

There was a high prevalence of overweight/obesity among veterans with MSD. High levels of BMI (>27 kg/m2) were associated with increased odds of pain, most markedly among veterans with osteoarthritis.

Evaluating context-specific evidence-based quality improvement intervention on lymphatic filariasis mass drug administration in Northern Ghana using the RE-AIM framework

Background

Over a decade of implementing a global strategy to eliminate lymphatic filariasis in Ghana through mass drug administration, the disease is still being transmitted in 11 districts out of an initial 98 endemic districts identified in 2000. A context-specific evidence-based quality improvement intervention was implemented in the Bole District of Northern Ghana after an initial needs assessment to improve the lymphatic filariasis mass drug administration towards eliminating the disease. Therefore, this study aimed to evaluate the process and impact of the lymphatic filariasis context-specific evidence-based quality improvement intervention in the Bole District of Northern Ghana.

Method

A cross-sectional mixed methods study using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to evaluate the context-specific evidence-based quality improvement intervention was employed. Quantitative secondary data was extracted from the neglected tropical diseases database. A community survey was conducted with 446 randomly selected participants. Qualitative data were collected from 42 purposively selected health workers, chiefs/opinion leaders and community drug distributors in the study area.

Results

The evaluation findings showed an improvement in social mobilisation and sensitisation, knowledge about lymphatic filariasis and mass drug administration process, willingness to ingest the medication and adherence to the direct observation treatment strategy. We observed an increase in coverage ranging from 0.1 to 12.3% after implementing the intervention at the sub-district level and reducing self-reported adverse drug reaction. The level of reach, effectiveness and adoption at the district, sub-district and individual participants’ level suggest that the context-specific evidence-based quality improvement intervention is feasible to implement in lymphatic filariasis hotspot districts based on initial context-specific needs assessment.

Conclusion

The study provided the groundwork for future application of the RE-AIM framework to evaluate the implementation of context-specific evidence-based quality improvement intervention to improve lymphatic filariasis mass drug administration towards eliminating the disease as a public health problem.

The LEAP Program: Quality Improvement Training to Address Team Readiness Gaps Identified by Implementation Science Findings

BACKGROUND

Integrating evidence-based innovations (EBIs) into sustained use is challenging; most implementations in health systems fail. Increasing frontline teams' quality improvement (QI) capability may increase the implementation readiness and success of EBI implementation.

OBJECTIVES

Develop a QI training program ("Learn. Engage. Act. Process." (LEAP)) and evaluate its impact on frontline obesity treatment teams to improve treatment delivered within the Veterans Health Administration (VHA).

DESIGN

This was a pre-post evaluation of the LEAP program. MOVE! coordinators (N = 68) were invited to participate in LEAP; 24 were randomly assigned to four starting times. MOVE! coordinators formed teams to work on improvement aims. Pre-post surveys assessed team organizational readiness for implementing change and self-rated QI skills. Program satisfaction, assignment completion, and aim achievement were also evaluated.

PARTICIPANTS

VHA facility-based MOVE! teams.

INTERVENTIONS

LEAP is a 21-week QI training program. Core components include audit and feedback reports, structured curriculum, coaching and learning community, and online platform.

MAIN MEASURES

Organizational readiness for implementing change (ORIC); self-rated QI skills before and after LEAP; assignment completion and aim achievement; program satisfaction.

KEY RESULTS

Seventeen of 24 randomized teams participated in LEAP. Participants' self-ratings across six categories of QI skills increased after completing LEAP (p< 0.0001). The ORIC measure showed no statistically significant change overall; the change efficacy subscale marginally improved (p < 0.08), and the change commitment subscale remained the same (p = 0.66). Depending on the assignment, 35 to 100% of teams completed the assignment. Nine teams achieved their aim. Most team members were satisfied or very satisfied (81-89%) with the LEAP components, 74% intended to continue using QI methods, and 81% planned to continue improvement work.

CONCLUSIONS

LEAP is scalable and does not require travel or time away from clinical responsibilities. While QI skills improved among participating teams and most completed the work, they struggled to do so amid competing clinical priorities.

Obesity Pharmacotherapy is Effective in the Veterans Affairs Patient Population: A Local and Virtual Cohort Study

OBJECTIVE

Obesity is a major public health challenge, and the US military veteran population is disproportionately affected. Using deidentified records from a local weight management clinic and a national clinical data repository, obesity pharmacotherapy use and effectiveness for weight loss and obesity comorbidities in this vulnerable population were assessed.

METHODS

During the initial year of the local clinic, 43 records with monthly follow-up of MOVE! lifestyle intervention augmented by obesity pharmacotherapy were found. Nationally, more than 2 million records of prescribed obesity pharmacotherapy compared with metformin as control were identified. Records with detailed documentation of weight trends from 1 year before to 1 year after the prescription date for further analysis were selected for review.

RESULTS

The most commonly prescribed medications in the local clinic were metformin, liraglutide, and combination phentermine/topiramate. On average, weight loss of -4.0 ± 2.1 kg over the initial 6-month intervention was observed. In the national cohort, 577,491 records with an obesity or control metformin prescription and adequate weight documentation were identified. The most effective pharmacotherapy in the national cohort was phentermine/topiramate (-0.0931 ± 0.0198 kg/wk difference), followed by liraglutide, lorcaserin, and orlistat.

CONCLUSIONS

Obesity pharmacotherapy is effective in achieving clinically meaningful weight loss in veterans as part of an integrated care approach.

Barriers and facilitators in implementing a pilot, pragmatic, telemedicine-delivered healthy lifestyle program for obesity management in a rural, academic obesity clinic

PURPOSE

Few evidence-based strategies are specifically tailored for disparity populations such as rural adults. Two-way video-conferencing using telemedicine can potentially surmount geographic barriers that impede participation in high-intensity treatment programs offering frequent visits to clinic facilities. We aimed to understand barriers and facilitators of implementing a telemedicine-delivered tertiary-care, rural academic weight-loss program for the management of obesity.

METHODS

A single-arm study of a 16-week, weight-loss pilot evaluated barriers and facilitators to program participation and exploratory measures of program adoption and staff confidence in implementation and intervention delivery. A program was delivered using video-conferencing within an existing clinical infrastructure. Elements of Consolidated Framework for Implementation Research (CFIR) provided a basis for assessing intervention characteristics, inner and outer settings, and individual characteristics using surveys and semi-structured interviews. We evaluated elements of the RE-AIM model (reach, adoption) to assess staff barriers to success for future scalability.

FINDINGS

There were 27 patients and 8 staff completing measures. Using CFIR, the intervention was valuable from a patient participant standpoint; staff equally had positive feelings about using telemedicine as useful for patient care. The RE-AIM framework demonstrated limited reach but willingness to adopt was above average. A significant barrier limiting sustainability was physical space for intervention delivery and privacy and dedicated resources for staff. Scheduling stressors were also a challenge in its implementation.

CONCLUSIONS

The need to engage staff, enhance organizational culture, and increase reach are major factors for rural health obesity clinics to enhance sustainability of using telemedicine for the management of obesity.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03309787. Registered on 16 October 2017.

Using an Adjunctive Treatment to Address Psychological Distress in a National Weight Management Program: Results of an Integrated Pilot Study

INTRODUCTION

Obesity is highly comorbid with psychological symptoms in veterans, particularly post-traumatic stress disorder (PTSD), depression, and anxiety. Obese veterans with comorbid psychological symptoms often display suboptimal weight loss and poor physical functioning when participating in weight management programs. The MOVE! program aims to increase healthy eating and physical activity to promote weight loss in obese veterans. Adequately addressing psychological barriers is necessary to maximize outcomes in MOVE! for veterans with PTSD, depression, and anxiety. We examined the preliminary outcomes of administering the Healthy Emotions and Improving Health BehavioR Outcomes (HERO) intervention. HERO is adjunctive cognitive-behavioral therapy to MOVE! that addresses PTSD, depression, and anxiety symptom barriers to engagement in physical activity.

MATERIALS AND METHODS

All recruitment and study procedures were approved by the institutional review board and research and development committees of the Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine in Houston, Texas. Participants gave written informed consent before enrollment. Thirty-four obese veterans with a diagnosis of PTSD, depression, and/or anxiety who were attending MOVE! were assigned to the 8-session HERO group or the usual care (UC) group. Veterans completed assessments of PTSD, depression and anxiety symptoms, physical activity, physical functioning, and weight at baseline, 8 and 16 weeks post treatment. Changes from baseline to 8- and 16-week follow-up on the self-report and clinician-rated measures were assessed, using independent samples t-tests and analyses of covariance.

RESULTS

At 8 weeks post treatment, participants in the HERO group had significantly higher step counts per day than participants in the UC group. Similarly, at 16 weeks post-treatment, participants in the HERO group continued to experience a significant increase in daily steps taken per day, as well as statistically and clinically significantly lower scores on the depression symptom and PTSD symptom severity. Participants in the HERO group also demonstrated significantly higher scores on the physical functioning inventory than participants in the UC group (44.1 ± 12.1 vs. 35.7 ± 10.7, P = 0.04) at 16 weeks post treatment.

CONCLUSIONS

Findings of this small trial have important implications pending replication in a more rigorously designed large-scale study. Providing an adjunctive treatment to MOVE! that addresses psychological distress has potential benefits for psychological symptom reduction, engagement in healthy dietary habits, and greater physical activity for individuals who traditionally experience barriers to making positive weight management changes.

Testing a self-directed lifestyle intervention among veterans: The D-ELITE pragmatic clinical trial

Nearly half of Veterans have obesity, fueling chronic diseases. The Department of Veterans Affairs (VA) offers an evidence-based behavioral weight management intervention called MOVE!, mostly delivered through in-person group sessions. Few eligible Veterans participate due to factors like distance and preferences, mirroring barriers in the general population. Practical alternatives to standard in-person programs are needed to improve access and engagement. A self-directed lifestyle intervention called D-ELITE-delivered through pre-recorded videos by DVD or online streaming-previously efficacious in a general primary care population, may provide such an alternative. This pragmatic clinical trial will evaluate whether D-ELITE improves weight and general health status among Veterans with obesity, relative to VA usual care. The yearlong intervention includes one orientation by phone, supplemental lifestyle coaching primarily via technology-based messages, 12 DVD or online streaming sessions over 3 months, and continued self-directed weight management for months 4-12. Participants use MyFitnessPal.com or paper booklets for self-monitoring weight, diet, and physical activity. Follow-up assessments at 12 and 24 months are administered by mail or phone. The study hypothesis is that compared with usual care, D-ELITE will lead to greater improvements in 12-month weight loss, per VA electronic health records, and general physical health status, assessed using the self-reported SF-12 physical composite score. We will also explore D-ELITE's effects on secondary biometric (e.g., HbA1c) and intermediate (e.g., diet) outcomes, reach, and budget impact. If effective, D-ELITE will offer a potentially scalable, low-cost alternative to VA's existing weight loss interventions by mitigating barriers presented by distance and technology.

Construction and Use of Body Weight Measures from Administrative Data in a Large National Health System: A Systematic Review

OBJECTIVE

Administrative data are increasingly used in research and evaluation yet lack standardized guidelines for constructing measures using these data. Body weight measures from administrative data serve critical functions of monitoring patient health, evaluating interventions, and informing research. This study aimed to describe the algorithms used by researchers to construct and use weight measures.

METHODS

A structured, systematic literature review of studies that constructed body weight measures from the Veterans Health Administration was conducted. Key information regarding time frames and time windows of data collection, measure calculations, data cleaning, treatment of missing and outlier weight values, and validation processes was collected.

RESULTS

We identified 39 studies out of 492 nonduplicated records for inclusion. Studies parameterized weight outcomes as change in weight from baseline to follow-up (62%), weight trajectory over time (21%), proportion of participants meeting weight threshold (46%), or multiple methods (28%). Most (90%) reported total time in follow-up and number of time points. Fewer reported time windows (54%), outlier values (51%), missing values (34%), or validation strategies (15%).

CONCLUSIONS

A high variability in the operationalization of weight measures was found. Improving methods to construct clinical measures will support transparency and replicability in approaches, guide interpretation of findings, and facilitate comparisons across studies.

Development of a Tailored Behavioral Weight Loss Program for Veterans With PTSD (MOVE!+UP): A Mixed-Methods Uncontrolled Iterative Pilot Study

PURPOSE

Veterans with post-traumatic stress disorder (PTSD) lose less weight in the Veterans Affairs (VA) weight management program (MOVE!), so we developed MOVE!+UP.

DESIGN

Single-arm pre-post pilot to iteratively develop MOVE!+UP (2015-2018).

SETTING

Veterans Affairs Medical Center.

PARTICIPANTS

Overweight Veterans with PTSD (5 cohorts of n = 5-11 [N = 44]; n = 39 received ≥1 MOVE+UP session, with cohorts 1-4 [n = 31] = "Development" and cohort 5 [n = 8] = "Final" MOVE!+UP).

INTERVENTION

MOVE!+UP weight management for Veterans with PTSD modified after each cohort. Final MOVE!+UP was coled by a licensed clinical psychologist and Veteran peer counselor in 16 two-hour in-person group sessions and 2 individual dietician visits. Sessions included general weight loss support (eg, behavioral monitoring with facilitator feedback, weekly weighing), cognitive-behavioral skills to address PTSD-specific barriers, and a 30-minute walk to a nearby park.

MEASURES

To inform post-cohort modifications, we assessed weight, PTSD, and treatment targets (eg, physical activity, diet), and conducted qualitative interviews.

ANALYSIS

Baseline to 16-week paired t tests and template analysis.

RESULTS

Development cohorts suggested improvements (eg, additional sessions and weight loss information, professional involvement) and did not lose weight (mean [M] = 1.8 lbs (standard deviation [SD] = 8.2); P = .29. Conversely, the final cohort reported high satisfaction and showed meaningful weight (M = -14 pounds [SD = 3.7] and 71% lost ≥5% baseline weight) and PTSD (M = -17.9 [SD = 12.2]) improvements, P < .05.

CONCLUSIONS

The comprehensive, 16-week, in-person, cofacilitated Final MOVE!+UP was acceptable and may improve the health of people with PTSD. Iterative development likely produced a patient-centered intervention, needing further testing.

Women Veterans Experience with the VA MOVE! Weight Management Program

Background: Obesity prevalence is higher in women veterans overall than their civilian counterparts considering 44% of women veterans are obese. Thus, there is a critical need to understand the facilitators and barriers to women veterans' participation in weight management programs. The objective of this study is to explore facilitators and barriers to weight loss for women veterans enrolled in the Veterans Health Administration Motivating Overweight/Obese Veterans Everywhere (VA MOVE!) weight management program and gather feedback on the design and delivery of the MOVE! program.

Materials and Methods: Primary qualitative data were collected from women veterans who completed at least one MOVE! visit via semistructured telephone interviews. Two authors independently reviewed transcripts for data-derived codes. A content analysis approach was used within the software to code the transcripts.

Results: The mean age of participants was 52 years. Sixty-eight percent (N = 17/25) were black, and 52% (N = 13/25) lived >64 kilometers from the location of the MOVE! program. Facilitators to participation included both intrinsic (e.g., drive to become healthy) and extrinsic (e.g., drive to improve laboratories) motivating factors. Women expressed difficulty with learning in a group setting and applying lessons to their everyday lives. Others reported the setup of group classes triggered their post-traumatic stress disorder and prevented them from fully participating in the program. Additional barriers included distance traveled to group sessions and lack of access to exercise space.

Conclusions: Our results illuminate barriers and facilitators to engagement in the MOVE! program. Many of the barriers highlighted by these women veterans mirror barriers civilian women face, highlighting the possibility that our results could be applied to other programs designed to target weight loss in women.

Dietary restraint and weight loss in relation to disinhibited eating in obese Veterans following a behavioral weight loss intervention

Ability to restrain one's dietary intake is a necessary skill for weight loss. However, dietary restraint has been shown to paradoxically increase disinhibited eating in certain populations, thereby negatively impacting weight loss and leading to worse overall health outcomes. The aim of this study was to address gaps in the literature regarding the relationships between separate facets of dietary restraint (intention; behavior) with weight loss and various types of disinhibited eating (binge eating, external eating, emotional eating) in overweight and obese adults who recently completed a weight loss intervention. A sample of mostly male Veterans with overweight and obesity (N = 88) self-reported their dietary restraint intention, restraint behavior, and current disinhibited eating following completion of an 8-week behavioral weight loss treatment. Greater dietary restraint intention was related to greater dietary restraint behavior, p < .05. Greater dietary restraint behavior was significantly related to greater recent weight loss, p < .05, while restraint intention was not, p > .05. Greater dietary restraint intention was related to greater current binge eating and external eating, while greater self-reported restraint behavior was related to less binge eating, p < .05. Thus, dietary restraint behavior appears to be adaptive for this population, whereas rigid dietary restraint intention may increase risk for disinhibited eating. To decrease disinhibited eating and improve weight loss outcomes in Veterans, interventions might specifically address rigid rule-following associated with abandonment of weight loss goals and help Veterans develop specific yet flexible eating plans. Future research should examine whether dietary restraint intention and behavior differentially predict disinhibited eating and weight loss outcomes prospectively.

Likelihood of Meeting Physical Activity Guidelines of Veterans Who Are Obese by Disability Status

PURPOSE

The purpose of this study was to explore the likelihood of meeting the physical activity guidelines in veterans who are obese by disability status.

DESIGN

We used data from the 2017 Behavioral Risk Factor Surveillance System, a cross-sectional telephone survey. The mean response rate was 44.9%.

SETTING

Respondents came from all 50 states, District of Columbia, and 3 US territories.

PATIENTS

Respondents included veterans self-reporting being obese (N = 13 798).

MEASURES

We created a mutually exclusive disability variable: no disability, multiple disability, and limitations only with hearing, vision, cognitive, mobility, Activities of Daily Living, or Instrumental Activities of Daily Living. Physical activity guidelines were defined as 150 minutes/week of aerobic activity and 2 days/week of strength activities.

ANALYSIS

Prevalence ratios (PRs) were calculated by performing separate log-binomial regression models for meeting strength and aerobic recommendations on veterans who were obese.

RESULTS

Obese veterans with mobility limitations only or multiple disabilities were significantly less likely to meet the aerobic (PR = 0.74, P = .002 and PR = .62, P = .021, respectively) or strength (PR = .76, P < .001 and PR = 0.74, P < .001, respectively) recommendations, compared to not having a disability (n = 7964).

CONCLUSIONS

Inactivity could be explained by a lack of inclusive weight loss programs for veterans with disabilities and barriers to physical activity encountered by people with disabilities. Two primary limitations of this study are self-report of obesity and physical activity and exclusion of adults in institutional settings.

Operationalizing the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework to evaluate the collective impact of autonomous community programs that promote health and well-being

Background

The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework is a useful tool for evaluating the impact of programs in community settings. RE-AIM has been applied to evaluate individual programs but seldom used to evaluate the collective impact of community-based, public health programming developed and delivered by multiple autonomous organizations. The purposes of this paper were to (a) demonstrate how RE-AIM can be operationalized and applied to evaluate the collective impact of similar autonomous programs that promote health and well-being and (b) provide preliminary data on the collective impact of Canadian spinal cord injury (SCI) peer mentorship programs on the delivery of peer mentorship services.

Methods

Criteria from all five RE-AIM dimensions were operationalized to evaluate multiple similar community-based programs. For this study, nine provincial organizations that serve people with SCI were recruited from across Canada. Organizations completed a structured self-report questionnaire and participated in a qualitative telephone interview to examine different elements of their peer mentorship program. Data were analyzed using summary statistics.

Results

Having multiple indicators to assess RE-AIM dimensions provided a broad evaluation of the impact of Canadian SCI peer mentorship programs. Peer mentorship programs reached 1.63% of the estimated Canadian SCI population. The majority (67%) of organizations tracked the effectiveness of peer mentorship through testimonials and reports. Setting-level adoption rates were high with 100% of organizations offering peer mentorship in community and hospital settings. On average, organizations allocated 10.4% of their operating budget and 9.8% of their staff to implement peer mentorship and 89% had maintained their programming for over 10 years. Full interpretation of the collective impact of peer mentorship programs was limited as complete data were only collected for 52% of survey questions.

Conclusions

The lack of available organizational data highlights a significant challenge when using RE-AIM to evaluate the collective impact of multiple programs that promote health and well-being. Although researchers are encouraged to use RE-AIM to evaluate the collective impact of programs delivered by different organizations, documenting limitations and providing recommendations should be done to further the understanding of how best to operationalize RE-AIM in these contexts.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7131-4) contains supplementary material, which is available to authorized users.

Effect of Obesogenic Medications on Weight-Loss Outcomes in a Behavioral Weight-Management Program

OBJECTIVE

This study aimed to evaluate a possible association between the use of obesogenic medications and inadequate weight loss in a behavioral weight-management program.

METHODS

This is a case-control, single-center study of 666 adult patients within a Veterans Health Administration health system who participated in the MOVE! behavioral weight-loss program. The cohort was divided into responders (n = 150), patients who achieved ≥ 5% total weight loss by the end of the MOVE! program, and nonresponders (n = 516), those who achieved < 5% total weight loss. We reviewed each patient's medical records for exposure to obesogenic medication during the time of treatment.

RESULTS

Approximately 62% (n = 411) of patients entering MOVE! had a prescription for obesogenic medications. Obesogenic medication use was associated with worse weight-loss outcomes, and participants were 37% less likely to achieve a clinically meaningful (≥ 5% total weight loss) outcome at the end of the MOVE! program (odds ratio, 0.633; 95% CI: 0.427-0.937; adjusted P = 0.022). Patients who received three or more medications (n = 72) had the greatest difficulty achieving 5% weight loss compared with the control group (odds ratio, 0.265; 95% CI: 0.108-0.646; adjusted P = 0.003).

CONCLUSIONS

The use of provider-prescribed obesogenic medications was associated with worse weight-loss outcomes in a behavioral weight-loss program. Closer scrutiny of patient medications is necessary to help improve outcomes of weight-loss treatments.

Goal-directed versus outcome-based financial incentives for weight loss among low-income patients with obesity: rationale and design of the Financial Incentives foR Weight Reduction (FIReWoRk) randomised controlled trial

INTRODUCTION

Obesity is a major public health challenge and exacerbates economic disparities through employment discrimination and increased personal health expenditures. Financial incentives for weight management may intensify individuals' utilisation of evidence-based behavioural strategies while addressing obesity-related economic disparities in low-income populations. Trials have focused on testing incentives contingent on achieving weight loss outcomes. However, based on social cognitive and self-determination theories, providing incentives for achieving intermediate behavioural goals may be more sustainable than incentivising outcomes if they enhance an individual's skills and self-efficacy for maintaining long-term weight loss. The objective of this paper is to describe the rationale and design of the Financial Incentives foR Weight Reduction study, a randomised controlled trial to test the comparative effectiveness and cost-effectiveness of two financial incentive strategies for weight loss (goal directed vs outcome based) among low-income adults with obesity, as well as compared with the provision of health behaviour change resources alone.

METHODS AND ANALYSIS

We are recruiting 795 adults, aged 18-70 years with a body mass index ≥30 kg/m2, from three primary care clinics serving residents of socioeconomically disadvantaged neighbourhoods in New York City and Los Angeles. All participants receive a 1-year commercial weight loss programme membership, self-monitoring tools (bathroom scale, food journal and Fitbit Alta HR), health education and monthly check-in visits. In addition to these resources, those in the two intervention groups can earn up to $750 over 6 months for: (1) participating in an intensive weight management programme, self-monitoring weight and diet and meeting physical activity guidelines (goal-directed arm); or (2) a ≥1.5% to ≥5% reduction in baseline weight (outcome-based arm). To maximise incentive efficacy, we incorporate concepts from behavioural economics, including immediacy of payments and framing feedback to elicit regret aversion. We will use generalised mixed effect models for repeated measures to examine intervention effects on weight at 6, 9 and 12 months.

ETHICS AND DISSEMINATION

Human research protection committees at New York University School of Medicine, University of California Los Angeles (UCLA) David Geffen School of Medicine and Olive-View-UCLA Medical Center granted ethics approval. We will disseminate the results of this research via peer-reviewed publications, conference presentations and meetings with stakeholders.

TRIAL REGISTRATION NUMBER

NCT03157713.

A technology-assisted health coaching intervention vs. enhanced usual care for Primary Care-Based Obesity Treatment: a randomized controlled trial

Background

Goals for Eating and Moving (GEM) is a technology-assisted health coaching intervention to improve weight management in primary care at the Veterans Health Administration (VHA) that we designed through prior rigorous formative studies. GEM is integrated within the patient-centered medical home and utilizes student health coach volunteers to counsel patients and encourage participation in VHA’s intensive weight management program, MOVE!. The primary aim of this study was to determine the feasibility and acceptability of GEM when compared to Enhanced Usual Care (EUC). Our secondary aim was to test the impact of GEM on weight, diet and physical activity when compared to EUC.

Methods

Veterans with a Body Mass Index ≥30 kg/m² or 25–29.9 kg/m² with comorbidities (n = 45) were recruited in two phases and randomized to GEM (n = 22) or EUC (n = 23). We collected process measures (e.g. number of coaching calls completed, number and types of lifestyle goals, counseling documentation) and qualitative feedback on quality of counseling and acceptability of call duration. We also measured weight and behavioral outcomes.

Results

GEM participants reported receiving high quality counseling from health coaches and that call duration and frequency were acceptable. They received 5.9 (SD = 3.7) of 12 coaching calls on average, and number of coaching calls completed was associated with greater weight loss at 6-months in GEM participants (Spearman Coefficient = 0.71, p < 0.001). Four participants from GEM and two from EUC attended the MOVE! program. PCPs completed clinical reminders in 12% of PCP visits with GEM participants. Trends show that GEM participants (n = 21) tended to lose more weight at 3-, 6-, and 12-months as compared to EUC, but this was not statistically significant. There were no significant differences in diet or physical activity.

Conclusions

We found that a technology assisted health coaching intervention delivered within primary care using student health coaches was feasible and acceptable to Veteran patients. This pilot study helped elucidate challenges such as low provider engagement, difficulties with health coach continuity, and low patient attendance in MOVE! which we have addressed and plan to test in future studies.

Trial registration

NCT03006328 Retrospectively registered on December 30, 2016.

Electronic supplementary material

The online version of this article (10.1186/s40608-018-0226-0) contains supplementary material, which is available to authorized users.

Geographic Variation in Obesity, Behavioral Treatment, and Bariatric Surgery for Veterans

OBJECTIVE

This study aims to describe geographic variation in veterans' prevalence of obesity, participation in Veterans Health Administration's behavioral weight management program (MOVE!), and receipt of bariatric surgery in fiscal year (FY) 2016.

METHODS

In this retrospective cohort study of veterans with obesity who received Veterans Health Administration care in FY2016, electronic health record data were obtained on weight, height, outpatient visits to the MOVE! program, and bariatric surgeries. For each Veterans Integrated Service Network (VISN) region, the prevalence rate of veterans with obesity (BMI ≥ 30 kg/m² ), MOVE! participation rates, and bariatric surgery rates are presented.

RESULTS

The prevalence of obesity in veterans ranged from 30.5% to 40.5% across VISNs in FY2016. MOVE! participation among veterans with obesity was low (2.8%-6.9%) across all VISNs, but veterans with class II and III obesity (BMI ≥ 35) had higher MOVE! participation rates (4.3%-10.8%) than veterans with class I obesity. There was 20-fold variation across VISNs in receipt of bariatric surgery among veterans with BMI ≥ 35, ranging from 0.01% to 0.2%. Among veterans with BMI ≥ 35 participating in MOVE!, there was 46-fold variation in bariatric surgery provision, ranging from 0.07% to 3.27%.

CONCLUSIONS

Despite veterans' high prevalence of obesity, behavioral and surgical weight management participation is low and varies across regions.

Weight Reduction Goal Achievement Among Veterans With Mental Health Diagnoses

BACKGROUND: Despite the use of weight management programs among veterans, the impact of mental health diagnoses on weight reduction goal achievement is unknown. AIMS: We aimed to describe the prevalence and association of mental health diagnoses with a 5% weight reduction goal achievement. METHODS: Logistic regression was used to describe the association between mental health diagnoses and weight reduction goal achievement at 6, 12, and 24 months among 402 veterans enrolled in a weight management program. RESULTS: More than 43% of veterans had a mental health diagnoses, with depressive disorders, posttraumatic stress disorder (PTSD), and substance use disorders being the most prevalent. At all three times, simply having a mental health diagnosis was not associated with weight reduction goal achievement. Specific diagnoses were associated with a greater likelihood of achieving weight reduction goals at 12 months (PTSD and Drug Use Disorder) and 24 months (Anxiety Disorder and Other Mental Health Diagnosis). CONCLUSION: The findings suggest that unhealthy weight is quite common for individuals with mental health diagnoses; however, weight reduction goal achievement may be equally likely for those with and without mental health diagnoses. The prevalence of mental health diagnoses among veterans seeking weight reduction suggests that psychiatric nurses should be aware of this common comorbidity.

Changing Diet and Physical Activity in Nurses: A Pilot Study and Process Evaluation Highlighting Challenges in Workplace Health Promotion

OBJECTIVE

To use the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate and understand key implementation and context factors of a diet and physical activity (PA) workplace intervention for nurses.

METHODS

A 3-month pilot intervention was developed to promote diet and PA behavior through self-monitoring, goal setting, and social support using pedometers, a smartphone app, and a dedicated Facebook group. Measures included diet quality, daily PA, adoption, and implementation (including qualitative data). Maintenance was assessed at 6-month follow-up.

RESULTS

Forty-seven nurses participated in the study. At 3 months, fruit and vegetable intake significantly increased (P = .04) whereas PA significantly decreased (P = .01). The intervention was partially adopted as planned, with low reach and efficacy. Participants reported that changing 2 behaviors at the same time was difficult, with the majority feeling it was easier to change diet than to become more physically active.

CONCLUSIONS AND IMPLICATIONS

The ability to change diet and PA behaviors at the same time was challenging in nurses. Future studies examining whether similar occupational groups with high stress, fatigue, and lack of time face the same challenges would contribute to understanding these results.

The Phased Implementation of a National Telehealth Weight Management Program for Veterans: Mixed-Methods Program Evaluation

Background

The burden of obesity is high among US veterans, yet many face barriers to engaging in in-person, facility-based treatment programs. To improve access to weight-management services, the Veterans Health Administration (VHA) developed TeleMOVE, a home-based, 82-day curriculum that utilizes in-home messaging devices to promote weight loss in VHA patients facing barriers to accessing facility-based services.

Objective

The primary aim was to establish preliminary evidence for the program by comparing outcomes for TeleMOVE with standard, facility-based MOVE weight-management services (group, individual modalities) over the evaluation period based on the number of patients enrolled per site and the program’s clinical effectiveness, as demonstrated by average weight lost per patient. The secondary aim was to understand factors influencing TeleMOVE implementation variability across demonstration sites to develop recommendations to improve national program dissemination.

Methods

We employed a formative mixed-methods design to evaluate the phased implementation of TeleMOVE at 9 demonstration sites and compare patient- and site-level measures of program uptake. Data were collected between October 1, 2009 and September 30, 2011. Patient-level program outcomes were extracted from VHA patient care databases to evaluate program enrollment rates and clinical outcomes. To assess preliminary clinical effectiveness, weight loss outcomes for veterans who enrolled in TeleMOVE were compared with outcomes for veterans enrolled in standard MOVE! at each demonstration site, as well as with national averages during the first 2 years of program implementation. For the secondary aim, we invited program stakeholders to participate in 2 rounds of semistructured interviews about aspects of TeleMOVE implementation processes, site-level contextual factors, and program delivery. Twenty-eight stakeholders participated in audio-recorded interviews.

Results

Although stakeholders at 3 sites declined to be interviewed, objective program uptake was high at 2 sites, delayed-high at 2 sites, and low at 5 sites. At 6 months post enrollment, the mean weight loss was comparable for TeleMOVE (n=417) and MOVE! (n=1543) participants at −5.2 lb (SD 14.4) and −5.1 lb (SD 12.2), respectively (P=.91). All sites reported high program complexity because TeleMOVE required more staff time per participant than MOVE! due to logistical and technical assistance issues related to the devices. High-uptake sites overcame implementation challenges by leveraging communication networks with stakeholders, adapting the program to patient needs whenever possible, setting programmatic goals and monitoring feedback of results, and taking time to reflect and evaluate on delivery to foster incremental delivery improvements, whereas low-uptake sites reported less leadership support and effective communication among stakeholders.

Conclusions

This implementation evaluation of a clinical telehealth program demonstrated the value of partnership-based research in which researchers not only provided operational leaders with feedback regarding the effectiveness of a new program but also relevant feedback into contextual factors related to program implementation to enable adaptations for national deployment efforts.

A Coaching by Telephone Intervention on Engaging Patients to Address Modifiable Cardiovascular Risk Factors: a Randomized Controlled Trial

BACKGROUND

A large proportion of deaths and chronic illnesses can be attributed to three modifiable risk factors: tobacco use, overweight/obesity, and physical inactivity.

OBJECTIVE

To test whether telephone-based health coaching after completion of a comprehensive health risk assessment (HRA) increases patient activation and enrollment in a prevention program compared to HRA completion alone.

DESIGN

Two-arm randomized trial at three sites.

SETTING

Primary care clinics at Veterans Affairs facilities.

PARTICIPANTS

Four hundred seventeen veterans with at least one modifiable risk factor (BMI ≥ 30, < 150 min of at least moderate physically activity per week, or current smoker).

INTERVENTION

Participants completed an online HRA. Intervention participants received two telephone-delivered health coaching calls at 1 and 4 weeks to collaboratively set goals to enroll in, and attend structured prevention programs designed to reduce modifiable risk factors.

MEASUREMENTS

Primary outcome was enrollment in a structured prevention program by 6 months. Secondary outcomes were Patient Activation Measure (PAM) and Framingham Risk Score (FRS).

RESULTS

Most participants were male (85%), white (50%), with a mean age of 56. Participants were eligible, because their BMI was ≥ 30 (80%), they were physically inactive (50%), and/or they were current smokers (39%). When compared to HLA only at 6 months, health coaching intervention participants reported higher rates of enrollment in a prevention program, 51 vs 29% (OR = 2.5; 95% CI: 1.7, 3.9; p < 0.0001), higher rates of program participation, 40 vs 23% (OR = 2.3; 95% CI: 1.5, 3.6; p = 0.0004), and greater improvement in PAM scores, mean difference 2.5 (95% CI: 0.2, 4.7; p = 0.03), but no change in FRS scores, mean difference 0.7 (95% CI - 0.7, 2.2; p = 0.33).

CONCLUSIONS

Brief telephone health coaching after completing an online HRA increased patient activation and increased enrollment in structured prevention programs to improve health behaviors. CLINICALTRIALS.

GOV IDENTIFIER

NCT01828567.

Feasibility, Acceptability, and Exploratory Outcomes of Acceptance and Commitment Therapy for Binge Eating Symptoms in Veterans: A Preliminary Clinic-Based Study

Overweight and obesity are disabling problems for veterans and place a heavy toll on their physical and mental health. Acceptance and commitment therapy (ACT) is an empirically supported intervention that shows promise in improving binge eating, weight, and psychological functioning. This preliminary study evaluated the feasibility and acceptability of an 8-week ACT group intervention for binge eating in veterans (N = 85) who were overweight or obese and explored preliminary intervention effects on binge eating and physical and mental health functioning. Veterans were predominantly male (86.7%) with an average age of 58 years, and 65% endorsed clinically significant binge eating. Qualitative results indicated the majority of veterans found the intervention useful. Baseline to post-treatment comparisons found significant reductions in binge eating symptoms, depression, global psychological distress, and body mass index, as well as improvement in functioning. Findings suggest implementing ACT for binge eating in veterans is feasible and deserves further exploration, addressing binge eating and weight control. Future studies should examine ACT for this population in a randomized controlled trial.

Perceived barriers and facilitators of initiation of behavioral weight loss interventions among adults with obesity: a qualitative study

Background

Evidence-based behavioral weight loss interventions are under-utilized. To inform efforts to increase uptake of these interventions, it is important to understand the perspectives of adults with obesity regarding barriers and facilitators of weight loss intervention initiation.

Methods

We conducted a qualitative study in adults with obesity who had recently attempted weight loss either with assistance from an evidence-based behavioral intervention (intervention initiators) or without use of a formal intervention (intervention non-initiators). We recruited primary care patients, members of a commercial weight loss program, and members of a Veterans Affairs weight loss program. Intervention initiators and non-initiators were interviewed separately using a semi-structured interview guide that asked participants about barriers and facilitators of weight loss intervention initiation. Conversations were audio-recorded and transcribed. Data were analyzed with qualitative content analysis. Two researchers used open coding to generate the code book on a subset of transcripts and a single researcher coded remaining transcripts. Codes were combined into subthemes, which were combined in to higher order themes. Intervention initiators and non-initiators were compared.

Results

We conducted three focus groups with participants who had initiated interventions (n = 26) and three focus groups (n = 24) and 8 individual interviews with participants who had not initiated interventions. Intervention initiators and non-initiators were, respectively, 65% and 37.5% white, 62% and 63% female, mean age of 55 and 54 years old, and mean BMI of 34 kg/m². Three themes were identified. One theme was practical factors, with subthemes of reasonable cost and scheduling compatibility. A second theme was anticipated effectiveness of intervention, with subthemes of intervention content addressing individual needs; social aspects influencing effectiveness; and evaluating evidence of effectiveness. A third theme was anticipated pleasantness of intervention, with subthemes of social aspects influencing enjoyment; anticipated dietary and tracking prescriptions; and identity and self-reliance factors. Different perspectives were identified from intervention initiators and non-initiators.

Conclusions

Strategies to engage individuals in evidence-based weight loss interventions can be developed using these results. Strategies could target individuals’ perceived barriers and benefits to initiating interventions, or could focus on refining interventions to appeal to more individuals.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5795-9) contains supplementary material, which is available to authorized users.

Systematic Review of Behavioral Weight Management Program MOVE! for Veterans

CONTEXT

Since 2006, the Veterans Health Administration has delivered a population-based behavioral weight management program (MOVE!) to Veterans, which numerous studies have examined. The purpose of this study was to systematically review these studies to understand MOVE! participation rates and the association between MOVE! participation and weight change.

EVIDENCE ACQUISITION

A December 2016 PubMed search identified 320 English-language abstracts published between January 1, 2005 and December 31, 2016, of which 42 underwent full-text review. Twenty-six articles were determined to be eligible for final inclusion and data elements extracted from these articles included study years, study design, content of MOVE! and control intervention (if any), inclusion/exclusion criteria, initial sample size and sample loss, intervention duration and follow-up, patient characteristics, and outcomes. Quality was assessed using the Newcastle-Ottawa Quality Scale.

EVIDENCE SYNTHESIS

Studies were judged to be of good quality. Twenty-one of the 26 studies were retrospective cohort studies, one was a prospective cohort study and four were randomized trials. Program participation varied substantially (2%-12%) across studies. Six-month weight loss ranged from -0.95 kg to -1.84 kg, whereas 12-month weight loss ranged from -0.13 kg to -3.3 kg. A maximum of 25% of MOVE! users engaged in intense and sustained participation (eight or more visits within 6 months), but higher participation levels were consistently associated with greater weight change (-1.18 kg to -5.3 kg at 6 months, -1.68 kg to -3.58 kg at 12 months).

CONCLUSIONS

MOVE! participation is associated with modest short-term weight loss, with greater weight loss as participation increases. More research is needed to understand the barriers and facilitators to participation and the effect of MOVE! participation on long-term health and economic outcomes.

Implementation of a prediabetes identification algorithm for overweight and obese Veterans

Type 2 diabetes prevention is an important national goal for the Veteran Health Administration (VHA): one in four Veterans has diabetes. We implemented a prediabetes identification algorithm to estimate prediabetes prevalence among overweight and obese Veterans at Department of Veterans Affairs (VA) medical centers (VAMCs) in preparation for the launch of a pragmatic study of Diabetes Prevention Program (DPP) delivery to Veterans with prediabetes. This project was embedded within the VA DPP Clinical Demonstration Project conducted in 2012 to 2015. Veterans who attended orientation sessions for an established VHA weight-loss program (MOVE!) were recruited from VAMCs with geographically and racially diverse populations using existing referral processes. Each site implemented and adapted the prediabetes identification algorithm to best fit their local clinical context. Sites relied on an existing referral process in which a prediabetes identification algorithm was implemented in parallel with existing clinical flow; this approach limited the number of overweight and obese Veterans who were assessed and screened. We evaluated 1,830 patients through chart reviews, interviews, and/or laboratory tests. In this cohort, our estimated prevalence rates for normal glycemic status, prediabetes, and diabetes were 29% (n = 530), 28% (n = 504), and 43% (n = 796), respectively. Implementation of targeted prediabetes identification programs requires careful consideration of how prediabetes assessment and screening will occur.

Effect of an obesity best practice alert on physician documentation and referral practices

The Centers for Medicare & Medicaid Services Electronic Health Record Meaningful Use Incentive Program requires physicians to document body mass index (BMI) and a follow-up treatment plan for adult patients with BMI ≥ 25. To examine the effect of a best practice alert on physician documentation of obesity-related care and referrals to weight management treatment, in a cluster-randomized design, 14 primary care clinics at an academic medical center were randomized to best practice alert intervention (n = 7) or comparator (n = 7). The alert was triggered when both height and weight were entered and BMI was ≥30. Both intervention and comparator clinics could document meaningful use by selecting a nutrition education handout within the alert. Intervention clinics could also select a referral option from the list of clinic and community-based weight management programs embedded in the alert. Main outcomes were proportion of eligible patients with (1) obesity-related documentation and (2) referral. There were 26,471 total primary care encounters with 12,981 unique adult patients with BMI ≥ 30 during the 6-month study period. Documentation doubled (17 to 33%) with implementation of the alert. However, intervention clinics were not significantly more likely to refer patients to weight management than comparator clinics (2.8 vs. 1.3%, p = 0.07). Although the alert was associated with increased physician meaningful use compliance, it was not an effective strategy for improving patient access to weight management services. Further research is needed to understand system-level characteristics that influence obesity management in primary care.

Weight and Veterans' Environments Study (WAVES) I and II: Rationale, Methods, and Cohort Characteristics

PURPOSE

To present the rationale, methods, and cohort characteristics for 2 complementary "big data" studies of residential environment contributions to body weight, metabolic risk, and weight management program participation and effectiveness.

DESIGN

Retrospective cohort.

SETTING

Continental United States.

PARTICIPANTS

A total of 3 261 115 veterans who received Department of Veterans Affairs (VA) health care in 2009 to 2014, including 169 910 weight management program participants and a propensity score-derived comparison group.

INTERVENTION

The VA MOVE! weight management program, an evidence-based lifestyle intervention.

MEASURES

Body mass index, metabolic risk measures, and MOVE! participation; residential environmental attributes (eg, food outlet availability and walkability); and MOVE! program characteristics.

ANALYSIS

Descriptive statistics presented on cohort characteristics and environments where they live.

RESULTS

Forty-four percent of men and 42.8% of women were obese, whereas 4.9% of men and 9.9% of women engaged in MOVE!. About half of the cohort had at least 1 supermarket within 1 mile of their home, whereas they averaged close to 4 convenience stores (3.6 for men, 3.9 for women) and 8 fast-food restaurants (7.9 for men, 8.2 for women). Forty-one percent of men and 38.6% of women did not have a park, and 35.5% of men and 31.3% of women did not have a commercial fitness facility within 1 mile.

CONCLUSION

Drawing on a large nationwide cohort residing in diverse environments, these studies are poised to significantly inform policy and weight management program design.

A marginalized two-part model with heterogeneous variance for semicontinuous data

Semicontinuous data, characterized by a point mass at zero followed by a positive, continuous distribution, arise frequently in medical research. These data are typically analyzed using two-part mixtures that separately model the probability of incurring a positive outcome and the distribution of positive values among those who incur them. In such a conditional specification, however, standard two-part models do not provide a marginal interpretation of covariate effects on the overall population. We have previously proposed a marginalized two-part model that yields more interpretable effect estimates by parameterizing the model in terms of the marginal mean. In the original formulation, a constant variance was assumed for the positive values. We now extend this model to a more general framework by allowing non-constant variance to be explicitly modeled as a function of covariates, and incorporate this variance into two flexible distributional assumptions, log-skew-normal and generalized gamma, both of which take the log-normal distribution as a special case. Using simulation studies, we compare the performance of each of these models with respect to bias, coverage, and efficiency. We illustrate the proposed modeling framework by evaluating the effect of a behavioral weight loss intervention on health care expenditures in the Veterans Affairs health system.