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Funk LM, Williams CB, Breuer CR, Hetzel S, LaSage SC, Villasenor CJ, Moin T, Cook J, Sampene E, Stroupe KT, Alagoz E, Raffa SD, Voils CI. The TOTAL trial for weight management participation: A randomized controlled trial protocol. Contemp Clin Trials 2024; 144:107611. [PMID: 38914310 PMCID: PMC11323199 DOI: 10.1016/j.cct.2024.107611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/28/2024] [Accepted: 06/21/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND The three types of evidence-based treatment options for adults with overweight and obesity - behavioral weight management, anti-obesity medications (AOM), and bariatric surgery - are underutilized in the Veterans Health Administration (VHA) system. Our objective in this manuscript is to describe the study protocol for an adequately powered randomized controlled trial (RCT) of a behavioral intervention: TOTAL (Teaching Obesity Treatment Options to Adult Learners) to increase patient uptake of obesity treatment. METHODS In this multi-site, parallel, RCT, eligible Veterans with a body mass index [BMI] ≥ 27 who had not received obesity treatment within the past 12 months were randomly assigned to TOTAL or usual care. TOTAL involves watching an 18-min video that highlights obesity health risks, pros/cons of all three evidence-based obesity treatments, and expected treatment outcomes. It also includes motivational sessions delivered via televideo at 2 weeks, 6 months, and 12 months after the video (target n = 494 participants). The primary outcome is initiation of behavioral weight management treatment within 18 months of randomization. Secondary outcomes include sustained behavioral weight management treatment, initiation of AOM, bariatric surgery referral, and weight change across 18 months. CONCLUSION TOTAL, which seeks to increase delivery of weight management treatment within the largest integrated health system in the U.S., combines patient education with motivational interviewing components. If efficacious in this trial, further evaluation of intervention effectiveness and implementation throughout the VHA and other healthcare systems would be warranted.
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Affiliation(s)
- Luke M Funk
- William S. Middleton Veterans Affairs Hospital, Madison, WI, USA; Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA.
| | | | - Catherine R Breuer
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Scott Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | | | | | - Tannaz Moin
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Jessica Cook
- William S. Middleton Veterans Affairs Hospital, Madison, WI, USA; Center for Tobacco Research and Intervention, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Emmanuel Sampene
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | - Kevin T Stroupe
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, IL, USA; Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, IL, USA
| | - Esra Alagoz
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Susan D Raffa
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; Veterans Health Administration National Center for Health Promotion and Disease Prevention, Washington, DC, USA
| | - Corrine I Voils
- William S. Middleton Veterans Affairs Hospital, Madison, WI, USA; Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
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Breland JY, Tanksley L, Borowitz MA, Houseknecht D, Muhammad N, Raffa SD, Hoerster KD. Black Veterans Experiences with and Recommendations for Improving Weight-Related Health Care: A Photovoice Study. J Gen Intern Med 2024; 39:2033-2040. [PMID: 38438635 PMCID: PMC11306895 DOI: 10.1007/s11606-024-08628-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 01/11/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Non-Hispanic Black or African American (hereafter Black) veterans lose less weight than other users of the Veterans Health Administration's (VHA) weight management program (MOVE!), despite higher enrollment. OBJECTIVE To understand factors that affect weight loss disparities between Black veterans and other veterans. DESIGN Qualitative study using Photovoice methods. PARTICIPANTS Self-identified Black veterans in MOVE! across the USA (two women, seven men). APPROACH We conducted six virtual Photovoice sessions with Black veterans. Session one provided orientation to the goal of understanding factors that might affect weight loss disparities. Participants chose missions related to weight management and VHA care, bringing photos or other media (e.g., poems) to discuss during remaining sessions. Facilitators/participants identified themes related to each session in real time. Between and after sessions, facilitators/investigators conducted rapid qualitative analysis of transcripts/audio to group similar themes, identify illustrative quotes/photos/other media, and prepare dissemination products (e.g., this manuscript). Participants provided feedback on the manuscript during an additional session. KEY RESULTS Themes were identified across three categories: (1) Food in Our Lives and Health Care; (2) Body Image; and (3) Healthcare Bias and Discrimination. The emotional impact of food and the negative effects of bias and discrimination on health care quality and trust were especially salient. Participants provided recommendations for weight-related and general care. Notable recommendations included the need for VHA to hire and retain providers-especially Black providers-who understand and respect Black patients and are committed to delivering evidence-based, culturally sensitive care. In addition, weight management care should be tailored to individual patients' diets and health beliefs and deemphasize body mass index. CONCLUSIONS Photovoice resulted in concrete targets that could reduce health disparities. Institutions should consider Photovoice and similar approaches to build trust with and incorporate input from marginalized communities. This approach requires sustained commitment from leaders to engage stakeholders and implement solutions.
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Affiliation(s)
- Jessica Y Breland
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA.
| | - Lamont Tanksley
- Mental Health Service, VA Puget Sound Healthcare System, Seattle Division, Seattle, WA, USA
| | - Michelle A Borowitz
- Mental Health Service, VA Puget Sound Healthcare System, Seattle Division, Seattle, WA, USA
| | - Dakota Houseknecht
- Health Services Research and Development, VA Puget Sound Healthcare System, Seattle Division, Seattle, WA, USA
| | - Na'imah Muhammad
- Health Services Research and Development, VA Puget Sound Healthcare System, Seattle Division, Seattle, WA, USA
| | - Susan D Raffa
- VA National Center for Health Promotion and Disease Prevention, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Katherine D Hoerster
- Mental Health Service, VA Puget Sound Healthcare System, Seattle Division, Seattle, WA, USA
- Health Services Research and Development, VA Puget Sound Healthcare System, Seattle Division, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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Vandyousefi S, Oettingen G, Wittleder S, Moin T, Sweat V, Aguilar AD, Ruan A, Angelotti G, Wong L, Orstad SL, Illengberger N, Nicholson A, Lim S, Cansler R, Portelli D, Sherman S, Jay MR. Protocol for a prospective, randomized, controlled trial of Mental Contrasting with Implementation Intentions (MCII) to enhance the effectiveness of VA's MOVE! weight management program: WOOP (Wish, Outcome, Obstacle, Plan) VA. Contemp Clin Trials 2024; 141:107523. [PMID: 38608752 DOI: 10.1016/j.cct.2024.107523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 03/31/2024] [Accepted: 04/08/2024] [Indexed: 04/14/2024]
Abstract
INTRODUCTION Intensive weight management programs are effective but often have low enrollment and high attrition. Lack of motivation is a key psychological barrier to enrollment, engagement, and weight loss. Mental Contrasting with Implementation Intentions (MCII) is a unique imagery technique that increases motivation for behavior change. We describe our study protocol to assess the efficacy and implementation of MCII to enhance the effectiveness of VA's MOVE! or TeleMOVE! weight management programs using a procedure called "WOOP" (Wish, Outcome, Obstacle, Plan) for Veterans. We hypothesize that WOOP+MOVE! or TeleMOVE! (intervention) will lead to greater MOVE!/TeleMOVE! program engagment and consequently weight loss than MOVE!/TeleMOVE! alone (control). METHOD Veterans are randomized to either the intervention or control. Both arms receive the either MOVE! or TeleMOVE! weight management programs. The intervention group receives an hour long WOOP training while the control group receives patient education. Both groups receive telephone follow up calls at 3 days, 4 weeks, and 2 months post-baseline. Eligible participants are Veterans (ages 18-70 years) with either obesity (BMI ≥ 30 kg/m2) or overweight (BMI ≥ 25 kg/m2) and an obesity-associated co-morbidity. At baseline, 6 and 12 months, we assess weight, diet, physical activity in both groups. The primary outcome is mean percent weight change at 6 months. Secondary outcomes include changes in waist circumference, diet, physical activity, and dieting self-efficacy and engagement in regular physical activity. We assess implementation using the RE-AIM framework. CONCLUSION If WOOP VA is found to be efficacious, it will be an important tool to facilitate weight management and improve weight outcomes. CLINICAL TRIAL REGISTRATION NCT05014984.
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Affiliation(s)
- Sarvenaz Vandyousefi
- New York Harbor Veterans Health Affairs, New York, NY, United States of America; Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Gabriele Oettingen
- Department of Psychology, New York University, New York, NY, United States of America
| | - Sandra Wittleder
- New York Harbor Veterans Health Affairs, New York, NY, United States of America; Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Tannaz Moin
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States of America; Department of Medicine, David Geffen School of Medicine, The University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Victoria Sweat
- New York Harbor Veterans Health Affairs, New York, NY, United States of America; Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Adrian D Aguilar
- New York Harbor Veterans Health Affairs, New York, NY, United States of America; Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Andrea Ruan
- New York Harbor Veterans Health Affairs, New York, NY, United States of America; Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Gina Angelotti
- New York Harbor Veterans Health Affairs, New York, NY, United States of America; Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Laura Wong
- New York Harbor Veterans Health Affairs, New York, NY, United States of America; Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Stephanie L Orstad
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Nicholas Illengberger
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Andrew Nicholson
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Sahnah Lim
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Rachel Cansler
- New York Harbor Veterans Health Affairs, New York, NY, United States of America; Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Dilara Portelli
- New York Harbor Veterans Health Affairs, New York, NY, United States of America; Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Scott Sherman
- New York Harbor Veterans Health Affairs, New York, NY, United States of America; Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America; Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Melanie R Jay
- New York Harbor Veterans Health Affairs, New York, NY, United States of America; Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America; Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America.
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Hung A, Pura JA, Stechuchak KM, Dennis PA, Maciejewski ML, Smith VA, Blalock DV, Hoerster K, Raffa SD, Wong E. Association between a national behavioral weight management program and real-world weight change. Obes Res Clin Pract 2024; 18:201-208. [PMID: 38851989 DOI: 10.1016/j.orcp.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/29/2024] [Accepted: 05/29/2024] [Indexed: 06/10/2024]
Abstract
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.
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Affiliation(s)
- Anna Hung
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; Duke-Margolis Center for Health Policy, Durham, NC, USA.
| | - John A Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA
| | - Paul A Dennis
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; Duke-Margolis Center for Health Policy, Durham, NC, USA; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Dan V Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, NC, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Katherine Hoerster
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Department of Health Services, University of Washington, Seattle, WA, USA; School of Medicine, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Susan D Raffa
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA; National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Durham, NC, USA
| | - Edwin Wong
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Department of Health Services, University of Washington, Seattle, WA, USA
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Zimmermann M, Greenberg L, Breland JY. Engagement and Use of a Blended mHealth Intervention for Health Behavior Change. Int J Behav Med 2024; 31:284-291. [PMID: 37217635 DOI: 10.1007/s12529-023-10182-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Blended mHealth interventions (mHealth interventions including a facilitator) promote user engagement and increase effectiveness of health behavior change interventions. Little is known about how blended mHealth interventions are used outside the research context. METHODS In the present work, we characterized patterns of app use among users of a blended mHealth intervention in real-world conditions. Program users were Veterans Health Administration (VHA) primary care patients (n = 56) who received an invite code for a blended mHealth intervention between 2019 and 2021. Cluster analysis was used to examine user engagement with health coach visits and program features. RESULTS Of patients who received an invite code, 34% initiated the program. Most users were men (63%) and white (57%). The mean number of health conditions was 5 (68% with obesity). The mean age was 55. Cluster analysis suggested that most users did sustain engagement at either moderate (57%) or very high levels (13%). The remaining 30% of users were low engaged users. Users completing any health coach visit (about half) reported more overall engagement than their counterparts who did not. Weight was the most frequently tracked metric. Of users entering weights in the first and last month of the program (n = 18), the mean percent body weight change was 4.0% (SD = 3.6). CONCLUSIONS A blended mHealth intervention may be a scalable option to extend the reach of health behavior change interventions for those that use it. However, a significant portion of users do not initiate these interventions, choose not to use the health coach feature, or engage at lower levels. Future research should examine the role of health coaching visits in promoting sustained engagement.
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Affiliation(s)
- Martha Zimmermann
- VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA, 94025, USA.
- Department of Psychiatry, UMass Chan Medical School, 222 Maple Ave, Shrewsbury, MA, 01545, USA.
| | - Lauren Greenberg
- VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA, 94025, USA
| | - Jessica Y Breland
- VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA, 94025, USA
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Breland JY, Raikov I, Hoggatt KJ, Phibbs CS, Maguen S, Timko C, Saechao F, Frayne SM. Behavioral weight management use in the Veterans Health Administration: Sociodemographic and health correlates. Eat Behav 2024; 53:101864. [PMID: 38489933 DOI: 10.1016/j.eatbeh.2024.101864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/23/2024] [Accepted: 02/25/2024] [Indexed: 03/17/2024]
Abstract
INTRODUCTION Over 40 % of United States Veterans Health Administration (VHA) primary care patients have obesity. Few patients use VHA's flagship weight management program, MOVE! and there is little information on other behavioral weight management program use. METHODS The national United States cohort included over 1.5 million primary care patients with obesity, age 18-79, based on VHA administrative data. Gender stratified multivariable logistic regression identified correlates of weight management use in the year after a patient's first primary care appointment (alpha of 0.05). Weight management use was defined as MOVE! or nutrition clinic visits. RESULTS The cohort included 121,235 women and 1,521,547 men with 13 % and 7 % using weight management, respectively. Point estimates for specific correlates of use were similar between women and men, and across programs. Black patients were more likely to use weight management than White patients. Several physical and mental health diagnoses were also associated with increased use, such as sleep apnea and eating disorders. Age and distance from VHA were negatively associated with weight management use. CONCLUSIONS When assessing multiple types of weight management visits, weight management care in VHA appears to be used more often by some populations at higher risk for obesity. Other groups may need additional outreach, such as those living far from VHA. Future work should focus on outreach and prevention efforts to increase overall use rates. This work could also examine the benefits of tailoring care for populations in greatest need.
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Affiliation(s)
- Jessica Y Breland
- VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA 94025, USA.
| | - Ivan Raikov
- VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA 94025, USA
| | - Katherine J Hoggatt
- San Francisco VA Health Care System, 4150 Clement St, San Francisco, CA 94121, USA; University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Ciaran S Phibbs
- VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA 94025, USA; Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
| | - Shira Maguen
- San Francisco VA Health Care System, 4150 Clement St, San Francisco, CA 94121, USA; University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Christine Timko
- VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA 94025, USA; Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
| | - Fay Saechao
- VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA 94025, USA
| | - Susan M Frayne
- VA Palo Alto Health Care System, 795 Willow Road (MPD-152), Menlo Park, CA 94025, USA; Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
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Smith VA, Stechuchak KM, Wong ES, Hung A, Dennis PA, Hoerster KD, Blalock DV, Raffa SD, Maciejewski ML. Association Between a National Behavioral Weight Management Program and Veterans Affairs Health Expenditures. Med Care 2024; 62:235-242. [PMID: 38458985 DOI: 10.1097/mlr.0000000000001981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
OBJECTIVE The association between participation in a behavioral weight intervention and health expenditures has not been well characterized. We compared Veterans Affairs (VA) expenditures of individuals participating in MOVE!, a VA behavioral weight loss program, and matched comparators 2 years before and 2 years after MOVE! initiation. METHODS Retrospective cohort study of Veterans who had one or more MOVE! visits in 2008-2017 who were matched contemporaneously to up to 3 comparators with overweight or obesity through sequential stratification on an array of patient characteristics, including sex. Baseline patient characteristics were compared between the two cohorts through standardized mean differences. VA expenditures in the 2 years before MOVE! initiation and 2 years after initiation were modeled using generalized estimating equations with a log link and distribution with variance proportional to the standard deviation (gamma). RESULTS MOVE! participants (n=499,696) and comparators (n=1,336,172) were well-matched, with an average age of 56, average body mass index of 35, and similar total VA expenditures in the fiscal year before MOVE! initiation ($9662 for MOVE! participants and $10,072 for comparators, standardized mean difference=-0.019). MOVE! participants had total expenditures that were statistically lower than matched comparators in the 6 months after initiation but modestly higher in the 6 months to 2 years after initiation, though differences were small in magnitude (1.0%-1.6% differences). CONCLUSIONS The VA's system-wide behavioral weight intervention did not realize meaningful short-term health care cost savings for participants.
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Affiliation(s)
- Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
- Department of Medicine, Division of General Internal Medicine, School of Medicine, Duke University, Durham, NC
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
| | - Edwin S Wong
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA
| | - Anna Hung
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC
| | - Paul A Dennis
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Katherine D Hoerster
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, NC
| | - Dan V Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Durham, NC
| | - Susan D Raffa
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, NC
- National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Durham, NC
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
- Department of Medicine, Division of General Internal Medicine, School of Medicine, Duke University, Durham, NC
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC
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Kaur J, Lee YL, Stortz E, Palani G, Elkin B, Gravely A, Westanmo A, Billington CJ, Ercan-Fang N, Sibley SD. Telephone Virtual Versus In-Person Pharmacotherapy-Based Obesity Care: A COVID-19-Related Experience at a Veterans Administration Facility. Telemed J E Health 2024; 30:e1110-e1118. [PMID: 37883630 DOI: 10.1089/tmj.2023.0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
Background: Most of the Veterans Administration (VA) population is either overweight or obese, which is a serious health concern. Medical weight management visits have traditionally occurred through in-person clinics. However, the COVID-19 pandemic forced care delivery to virtual platforms. Methods: We compared weight loss with in-person versus telephone-based medical weight management (lifestyle counseling coupled with pharmacotherapy) delivered by physician and nurse practitioner visits during the pandemic. We designed a program evaluation utilizing a naturalistic (pragmatic) observational study structure, including both newly enrolled and previously established participants in the Minneapolis VA MOVE! program between 2017 and 2021. A "transition" cohort (n = 74) received in-person care from March 2019 to March 2020, and then transitioned to virtual care. A "new start" virtual care cohort (n = 149) enrolled after March 2020 was compared to a separate historical group (n = 180) that received in-person care between January 2017 and December 2019. Weight loss was accessed over a 9-month period in both cohorts. Results: Mean weight loss over 9 months was -6.5 ± 18.2 and -2.5 ± 13.3 lbs in the in-person and virtual phases of the transition cohort, respectively, without significant difference between the two phases (p = 0.22). Mean weight loss over 9 months in the new start (virtual) cohort was -14.4 ± 17.0 lbs compared to -16.7 ± 21.0 lbs in the historical cohort, without significant difference between groups (p = 0.44). Conclusions: In our naturalistic study in a single-site VA clinic setting, weight loss with telephone-based medical weight management during the pandemic was comparable to in-person care. These findings are important for veterans living in rural and/or underserved areas.
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Affiliation(s)
- Jasleen Kaur
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Yee L Lee
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ethan Stortz
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Guru Palani
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Baila Elkin
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Amy Gravely
- Research Service, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Anders Westanmo
- Department of Pharmacy, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Charles J Billington
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Nacide Ercan-Fang
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Shalamar D Sibley
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
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9
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Hung A, Wong ES, Dennis PA, Stechuchak KM, Blalock DV, Smith VA, Hoerster K, Vimalananda VG, Raffa SD, Maciejewski ML. Real World Use of Anti-Obesity Medications and Weight Change in Veterans. J Gen Intern Med 2024; 39:519-528. [PMID: 37962730 PMCID: PMC10973309 DOI: 10.1007/s11606-023-08501-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023]
Abstract
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.
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Affiliation(s)
- Anna Hung
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Durham, NC, USA.
| | - Edwin S Wong
- Seattle-Denver COIN, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Medicine, Seattle, WA, USA
| | - Paul A Dennis
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Dan V Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Katherine Hoerster
- Seattle-Denver COIN, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Medicine, Seattle, WA, USA
| | - Varsha G Vimalananda
- Center for Healthcare Organization and Implementation Research, VA Bedford Medical Center, Bedford, MA, USA
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Susan D Raffa
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Durham, NC, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
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10
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Wong ES, Stechuchak KM, Smith VA, Hung A, Dennis PA, Hoerster KD, Maciejewski ML. Differences in healthcare costs over 10 years following discharge from military service by weight trajectory. Obes Res Clin Pract 2024; 18:88-93. [PMID: 38565463 DOI: 10.1016/j.orcp.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/04/2024]
Abstract
The prevalence of overweight and obesity among military personnel has increased substantially in the past two decades. Following military discharge many personnel can receive integrated health care from the Veterans Health Administration. Prior research related to the economic impacts of obesity has not examined health care costs following the transition into civilian life following military discharge. To address this evidence gap, this study sought to compare longitudinal costs over 10 years across weight categories among VA enrollees recently discharged from the military.
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Affiliation(s)
- Edwin S Wong
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, MS-152, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington, 3980 15th Ave. NE, Seattle, WA 98195, USA.
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC 27705, USA
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC 27705, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC 27701, USA; Division of General Internal Medicine, Department of Medicine, Duke University, 200 Morris St., Durham, NC 27701, USA
| | - Anna Hung
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC 27705, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC 27701, USA
| | - Paul A Dennis
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC 27705, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC 27701, USA
| | - Katherine D Hoerster
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, MS-152, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington, 3980 15th Ave. NE, Seattle, WA 98195, USA; Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St., Seattle, WA 98195, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC 27705, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Durham, NC 27701, USA; Division of General Internal Medicine, Department of Medicine, Duke University, 200 Morris St., Durham, NC 27701, USA; Duke-Margolis Center for Health Policy, Duke University, 100 Fuqua Drive, Box 90120, Durham, NC 27708, USA
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11
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Dawson DB, Mohankumar R, Puran D, Nevedal A, Maguen S, Timko C, Kunik ME, Breland JY. Weight Management Treatment Representations: A Novel Use of the Common Sense Model. J Clin Psychol Med Settings 2023; 30:884-892. [PMID: 36828990 DOI: 10.1007/s10880-023-09946-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 02/26/2023]
Abstract
We used the Common Sense Model to understand weight management treatment representations of diverse patients, conducting semistructured interviews with 24 veterans with obesity, recruited from multiple U.S. Veterans Health Administration facilities. We performed a directed content analysis to summarize representations and assess differences across demographic groups. Patients' representations were impacted by gender, socioeconomic status, and disability status, creating group differences in available treatment (e.g., disability-related limitations), negative consequences (e.g., expense), treatment timeline (e.g., men emphasized long-term lifestyle changes), and treatment models (e.g., women described medically driven models). Patients identified conventional representations aligning with medical recommendations and relating to positive consequences, long-term treatment timelines, and medically driven models. Finally, patients discussed risky representations, including undesirable attitudes related to short-term positive and negative consequences and long-term negative consequences. Applying the Common Sense Model emphasized diverse representations, influenced by patients' identities. Understanding representations may improve treatment to meet the needs of diverse preferences.
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Affiliation(s)
- Darius B Dawson
- South Central Mental Illness Research, Education, and Clinical Center, Houston, TX, USA.
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
- Houston VA HRS&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.
- , (MEDVAMC 152), 2002 Holcombe Blvd., Houston, TX, 77030, USA.
| | - Rakshitha Mohankumar
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, USA
| | - Deloras Puran
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, USA
| | - Andrea Nevedal
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, USA
| | - Shira Maguen
- Mental Health Service, San Francisco VA Health Care System, Menlo Park, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Christine Timko
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Mark E Kunik
- South Central Mental Illness Research, Education, and Clinical Center, Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Houston VA HRS&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Jessica Y Breland
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, USA
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12
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Breland JY, Fletcher TL, Maguen S, Timko C, Raikov I, Boothroyd DB, Frayne SM. The EMBER trial for weight management engagement: A hybrid type 1 randomized controlled trial protocol. Contemp Clin Trials 2023; 135:107364. [PMID: 37884122 DOI: 10.1016/j.cct.2023.107364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/13/2023] [Accepted: 10/23/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Almost 40% of Veterans Health Administration (VHA) users have obesity. VHA's national weight management program is associated with weight loss and improved health. However, while 94% of eligible VHA users are offered weight management programs, <8% use them. We developed EMBER - a novel, Motivational Interviewing-based, self-help tool - with the goal of Enhancing Motivation for Better Engagement and Reach for weight management. EMBER is not a weight management program; instead it engages people in existing programs by informing and guiding choices about weight management. METHODS The EMBER Trial is a randomized hybrid type 1 effectiveness implementation trial. Participants are Palo Alto or Houston VA Health Care System users with obesity who have not used a VHA weight management program in the past two years (target N = 470). Participants are randomly assigned to EMBER or an information-only control condition, after which they receive materials on paper or digitally, per their preference. The trial's primary goal is to determine whether participants randomized to EMBER are more likely to have any weight management engagement at two-month follow-up compared to those in the control condition. Secondary outcomes include 6-month retention in weight management, weight management behaviors, weight loss, quality of life, and implementation outcomes (e.g., reach, appropriateness). CONCLUSION EMBER is the first self-directed, Motivational Interviewing-based intervention designed to increase weight management program engagement. The study takes a low-touch, population health approach that could be modified for other programs if effective. The Hybrid Type 1 design will ensure results can be scaled and sustained.
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Affiliation(s)
- Jessica Y Breland
- VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System and Michael E DeBakey VA Medical Center, 795 Willow Road (MPD-152), Menlo Park, CA 94025, USA.
| | - Terri L Fletcher
- VA HSR&D Houston Center of Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VHA Medical Center, 2002 Holcombe Blvd, Houston, TX 77030, USA; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd, Houston, TX 77030, USA; VA South Central Mental Illness Research, Education and Clinical Center, Virtual Center, USA
| | - Shira Maguen
- San Francisco VHA Health Care System, 4150 Clement St, San Francisco, CA 94121, USA; University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Christine Timko
- VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System and Michael E DeBakey VA Medical Center, 795 Willow Road (MPD-152), Menlo Park, CA 94025, USA; Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
| | - Ivan Raikov
- VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System and Michael E DeBakey VA Medical Center, 795 Willow Road (MPD-152), Menlo Park, CA 94025, USA; Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
| | - Derek B Boothroyd
- VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System and Michael E DeBakey VA Medical Center, 795 Willow Road (MPD-152), Menlo Park, CA 94025, USA; Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation, VA Palo Alto Health Care System and Michael E DeBakey VA Medical Center, 795 Willow Road (MPD-152), Menlo Park, CA 94025, USA; Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
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13
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Abstract
Importance Obesity affects approximately 42% of US adults and is associated with increased rates of type 2 diabetes, hypertension, cardiovascular disease, sleep disorders, osteoarthritis, and premature death. Observations A body mass index (BMI) of 25 or greater is commonly used to define overweight, and a BMI of 30 or greater to define obesity, with lower thresholds for Asian populations (BMI ≥25-27.5), although use of BMI alone is not recommended to determine individual risk. Individuals with obesity have higher rates of incident cardiovascular disease. In men with a BMI of 30 to 39, cardiovascular event rates are 20.21 per 1000 person-years compared with 13.72 per 1000 person-years in men with a normal BMI. In women with a BMI of 30 to 39.9, cardiovascular event rates are 9.97 per 1000 person-years compared with 6.37 per 1000 person-years in women with a normal BMI. Among people with obesity, 5% to 10% weight loss improves systolic blood pressure by about 3 mm Hg for those with hypertension, and may decrease hemoglobin A1c by 0.6% to 1% for those with type 2 diabetes. Evidence-based obesity treatment includes interventions addressing 5 major categories: behavioral interventions, nutrition, physical activity, pharmacotherapy, and metabolic/bariatric procedures. Comprehensive obesity care plans combine appropriate interventions for individual patients. Multicomponent behavioral interventions, ideally consisting of at least 14 sessions in 6 months to promote lifestyle changes, including components such as weight self-monitoring, dietary and physical activity counseling, and problem solving, often produce 5% to 10% weight loss, although weight regain occurs in 25% or more of participants at 2-year follow-up. Effective nutritional approaches focus on reducing total caloric intake and dietary strategies based on patient preferences. Physical activity without calorie reduction typically causes less weight loss (2-3 kg) but is important for weight-loss maintenance. Commonly prescribed medications such as antidepressants (eg, mirtazapine, amitriptyline) and antihyperglycemics such as glyburide or insulin cause weight gain, and clinicians should review and consider alternatives. Antiobesity medications are recommended for nonpregnant patients with obesity or overweight and weight-related comorbidities in conjunction with lifestyle modifications. Six medications are currently approved by the US Food and Drug Administration for long-term use: glucagon-like peptide receptor 1 (GLP-1) agonists (semaglutide and liraglutide only), tirzepatide (a glucose-dependent insulinotropic polypeptide/GLP-1 agonist), phentermine-topiramate, naltrexone-bupropion, and orlistat. Of these, tirzepatide has the greatest effect, with mean weight loss of 21% at 72 weeks. Endoscopic procedures (ie, intragastric balloon and endoscopic sleeve gastroplasty) can attain 10% to 13% weight loss at 6 months. Weight loss from metabolic and bariatric surgeries (ie, laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass) ranges from 25% to 30% at 12 months. Maintaining long-term weight loss is difficult, and clinical guidelines support the use of long-term antiobesity medications when weight maintenance is inadequate with lifestyle interventions alone. Conclusion and Relevance Obesity affects approximately 42% of adults in the US. Behavioral interventions can attain approximately 5% to 10% weight loss, GLP-1 agonists and glucose-dependent insulinotropic polypeptide/GLP-1 receptor agonists can attain approximately 8% to 21% weight loss, and bariatric surgery can attain approximately 25% to 30% weight loss. Comprehensive, evidence-based obesity treatment combines behavioral interventions, nutrition, physical activity, pharmacotherapy, and metabolic/bariatric procedures as appropriate for individual patients.
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Affiliation(s)
- Arielle Elmaleh-Sachs
- Department of Medicine, Division of General Internal Medicine and Clinical Innovation, New York University Grossman School of Medicine, New York, New York
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
- Family Health Centers at NYU Langone, New York, New York
| | - Jessica L Schwartz
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Carolyn T Bramante
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis
| | - Jacinda M Nicklas
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora
| | - Kimberly A Gudzune
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Melanie Jay
- Department of Medicine, Division of General Internal Medicine and Clinical Innovation, New York University Grossman School of Medicine, New York, New York
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
- New York Harbor Veteran Affairs, New York, New York
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14
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Griauzde DH, Hershey C, Michaels J, Evans RR, Richardson CR, Heisler M, Kullgren JT, Saslow LR. A very low-carbohydrate diabetes prevention program for veterans with prediabetes: a single-arm mixed methods pilot study. Front Nutr 2023; 10:1069266. [PMID: 37266128 PMCID: PMC10230095 DOI: 10.3389/fnut.2023.1069266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 04/27/2023] [Indexed: 06/03/2023] Open
Abstract
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.
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Affiliation(s)
- Dina H. Griauzde
- VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, United States
| | - Cheryl Hershey
- VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Jamie Michaels
- VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | | | - Caroline R. Richardson
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, United States
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Michele Heisler
- VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, United States
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, United States
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, United States
| | - Jeffrey T. Kullgren
- VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, United States
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, United States
| | - Laura R. Saslow
- University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, United States
- University of Michigan School of Nursing, Ann Arbor, MI, United States
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15
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Blalock DV, Pura JA, Stechuchak KM, Dennis PA, Maciejewski ML, Smith VA, Hung A, Hoerster KD, Wong ES. BMI Trends for Veterans Up to 10 Years After VA Enrollment Following Military Discharge. J Gen Intern Med 2023; 38:1423-1430. [PMID: 36219304 PMCID: PMC9552734 DOI: 10.1007/s11606-022-07818-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 09/15/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Obesity (body mass index [BMI]≥30kg/m2) among US adults has tripled over the past 45 years, but it is unclear how this population-level weight change has occurred. OBJECTIVE We sought to identify distinct long-term BMI trajectories and examined associations with demographic and clinical characteristics. DESIGN The design was latent trajectory modeling over 10 years of a retrospective cohort. Subgroups were identified via latent class growth mixture models, separately by sex. Weighted multinomial logistic regressions identified factors associated with subgroup membership. PARTICIPANTS Participants were a retrospective cohort of 292,331 males and 62,898 females enrolled in VA. MAIN MEASURES The main outcome measure was 6-month average VA-measured BMI over the course of 10 years. Additional electronic health record measures on demographic, clinical, and services utilization characteristics were also used to characterize latent trajectories. KEY RESULTS Four trajectories were identified for men and for women, corresponding to standard BMI categories "normal weight" (BMI <25), "overweight" (BMI 25-29.99), and "with obesity" (BMI ≥30): "normal weight" and increasing (males: 28.4%; females: 22.8%), "overweight" and increasing (36.4%; 35.6%), "with obesity" and increasing (33.6%; 40.0%), and "with obesity" and stable (males: 1.6%) or decreasing (females: 1.6%). Race, ethnicity, comorbidities, mental health diagnoses, and mental health service utilization discriminated among classes. CONCLUSIONS BMI in the 10 years following VA enrollment increased modestly. VA should continue prioritizing weight management interventions to the large number of veterans with obesity upon VA enrollment, because the majority remain with obesity.
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Affiliation(s)
- Dan V Blalock
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - John A Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Paul A Dennis
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA.
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA.
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA.
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA.
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Anna Hung
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Katherine D Hoerster
- Seattle-Denver Center for Innovation, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Edwin S Wong
- Seattle-Denver Center for Innovation, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
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16
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Garvey WT, Cheng M, Ramasamy A, Smolarz BG, Park S, Kumar N, Kim N, DerSarkissian M, Bhak RH, Duh MS, Wu M, Hansen S, Young-Xu Y. Clinical and Cost Benefits of Anti-Obesity Medication for US Veterans Participating in the MOVE! Weight Management Program. Popul Health Manag 2023; 26:72-82. [PMID: 36735596 DOI: 10.1089/pop.2022.0227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- W Timothy Garvey
- UAB Diabetes Research Center, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mu Cheng
- Analysis Group, Inc., Boston, Massachusetts, USA
| | | | | | - Suna Park
- Analysis Group, Inc., Boston, Massachusetts, USA
| | - Neela Kumar
- Novo Nordisk, Inc., Plainsboro, New Jersey, USA
| | - Nina Kim
- Novo Nordisk, Inc., Plainsboro, New Jersey, USA
| | | | | | | | - Melody Wu
- Analysis Group, Inc., Boston, Massachusetts, USA
| | | | - Yinong Young-Xu
- Clinical Epidemiology Program, White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA
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17
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Hoerster KD, Hunter-Merrill R, Nguyen T, Rise P, Barón AE, McDowell J, Donovan LM, Gleason E, Lane A, Plumley R, Schooler M, Schuttner L, Collins M, Au DH, Ma J. Effect of a Remotely Delivered Self-directed Behavioral Intervention on Body Weight and Physical Health Status Among Adults With Obesity: The D-ELITE Randomized Clinical Trial. JAMA 2022; 328:2230-2241. [PMID: 36511927 PMCID: PMC9856350 DOI: 10.1001/jama.2022.21177] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/27/2022] [Indexed: 12/15/2022]
Abstract
Importance The effectiveness of remotely delivered, self-directed, weight loss programs in routine clinical practice is largely unknown. Objective To test whether a self-directed, remotely administered behavioral lifestyle intervention improves weight and self-reported general health status compared with usual care. Design, Setting, and Participants In this randomized clinical trial, 511 adults with a body mass index (BMI) of 30 or more and less than 45 (based on electronic health record [EHR] weight and height), were enrolled from 30 Veterans Health Administration (VHA) sites between February 15, 2018, and December 18, 2018 (final follow-up February 18, 2021). Interventions Participants were randomly assigned to the intervention group (n = 254) or the control group (n = 257). Both received usual care. Participants randomized to the intervention received Diabetes Prevention Program-based self-directed videos, handouts, and coaching messages via an online platform or US mail for 12 months. Main Outcomes and Measures Coprimary outcomes were weight measured in primary care and recorded in the EHR and self-reported general health status using the Medical Outcomes Study 12-Item Short Form Health Survey (SF-12) physical component score (PCS; higher scores are better [range, 0-100]) at the 12-month follow-up. The between-group minimal clinically important differences are 3 kg for weight and 5 points for the SF-12 PCS. Linear mixed models used weights and SF-12 PCS measured at either time point, with participants analyzed according to randomization assignment. Statistical significance for each coprimary outcome was based on a 2-sided α level of .025. Results Among 511 participants randomized (mean age, 57.4 [SD, 13.9] years; 231 female [45%]), 429 (84.0%) had EHR-based weights and 410 (80.2%) had SF-12 PCS data at 12 months. The unadjusted mean weight at 12 months declined from 102.7 kg to 99.8 kg in the intervention group compared with 101.9 kg to 101.0 kg in the control group (adjusted between-group mean difference, -1.93 [97.5% CI, -3.24 to -0.61]; P = .001). At 12 months, the unadjusted mean SF-12 PCS scores declined from 44.8 to 44.3 among intervention participants compared with 44.5 to 43.2 among control participants (adjusted between-group mean difference, intervention minus control, 0.69 [97.5% CI, -1.11 to 2.49]; P = .39). Cardiovascular events represented the highest percentage of serious adverse events, accounting for 25% of events in the intervention group and 35% in the control group. Conclusions and Relevance Among adults with obesity, a remotely delivered self-directed, behavioral lifestyle intervention, compared with usual care, resulted in statistically significantly greater weight loss at 12 months, although the difference was not clinically important. There was no significant difference in self-reported general physical health status at 12 months. Trial Registration ClinicalTrials.gov Identifier: NCT03260140.
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Affiliation(s)
- Katherine D. Hoerster
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, Seattle, Washington
- VA Puget Sound Healthcare System, Seattle Division, Mental Health Service, Seattle, Washington
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Rachel Hunter-Merrill
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, Seattle, Washington
| | - Tanya Nguyen
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, Seattle, Washington
| | - Peter Rise
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, Seattle, Washington
| | - Anna E. Barón
- Colorado School of Public Health, Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora
| | - Jennifer McDowell
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, Seattle, Washington
| | - Lucas M. Donovan
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
| | - Emily Gleason
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, Seattle, Washington
| | - Amber Lane
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, Seattle, Washington
| | - Robert Plumley
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, Seattle, Washington
| | - Mary Schooler
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, Seattle, Washington
| | - Linnaea Schuttner
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Margaret Collins
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, Seattle, Washington
| | - David H. Au
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Jun Ma
- Department of Medicine, University of Illinois at Chicago
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18
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Damschroder LJ, Miech EJ, Freitag MB, Evans R, Burns JA, Raffa SD, Goldstein MG, Annis A, Spohr SA, Wiitala WL. Facility-level program components leading to population impact: a coincidence analysis of obesity treatment options within the Veterans Health Administration. Transl Behav Med 2022; 12:1029-1037. [PMID: 36408955 DOI: 10.1093/tbm/ibac051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Laura J Damschroder
- Veterans Affairs Center for Clinical Management Research, VA MIDAS QUERI Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Edward J Miech
- Veterans Affairs Center for Health Information & Communication, VA EXTEND QUERI, Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Michelle B Freitag
- Veterans Affairs Center for Clinical Management Research, VA MIDAS QUERI Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Richard Evans
- Veterans Affairs Center for Clinical Management Research, VA MIDAS QUERI Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jennifer A Burns
- Veterans Affairs Center for Clinical Management Research, VA MIDAS QUERI Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Susan D Raffa
- National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Michael G Goldstein
- National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Durham, NC, USA.,Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI, USA
| | - Ann Annis
- College of Nursing, Michigan State University, East Lansing, MI, USA
| | - Stephanie A Spohr
- National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Durham, NC, USA
| | - Wyndy L Wiitala
- Veterans Affairs Center for Clinical Management Research, VA MIDAS QUERI Ann Arbor Healthcare System, Ann Arbor, MI, USA
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19
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Robinson CH, Thompto AJ, Lima EN, Damschroder LJ. Continuous quality improvement at the frontline: One interdisciplinary clinical team's four-year journey after completing a virtual learning program. Learn Health Syst 2022; 6:e10345. [PMID: 36263266 PMCID: PMC9576248 DOI: 10.1002/lrh2.10345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/08/2022] [Accepted: 09/11/2022] [Indexed: 11/07/2022] Open
Abstract
Background The Veterans Health Administration (VHA) is the largest integrated health system in the U.S. and has identified the learning health system as a strategic priority. Clinicians and staff engaging in active learning through continuous quality improvement (QI) is a key pillar for learning system maturity. An interdisciplinary frontline team at a VHA medical center participated in the Learn. Engage. Act. Process. (LEAP) virtual coaching program to learn how to conduct multidisciplinary team-based QI cycles of change. These clinicians lead and deliver the MOVE! weight management program, an evidence-based comprehensive lifestyle intervention. The team worked to continuously improve patient weight loss by engaging in incremental learning cycles of change. The aim of this study is to tell the story of this team's learning experience and the resulting positive reinforcing loop with patient outcomes. Methods This is a mixed methods case study description of one team that participated in the LEAP Program that provides hands-on QI learning for frontline teams with virtual coaching and a structured curriculum. Autoethnographic qualitative descriptions of team experiences over time illustrate this team's continued engagement in learning loops. Multilevel linear modeling was used to assess patient outcomes before vs after the team's participation in LEAP. Results The team's participation in LEAP provided a set of fundamental QI skills and established a commitment to continual learning. Incremental improvements led to significant weight loss for patients who participated in MOVE! after the team completed LEAP (mean = 9.80 pounds; SD 10.43) compared to the pre-LEAP time period (mean = -6.83 pounds; SD 9.63). Conclusions Despite competing priorities and time limitations, this team's experiences provide a positive vision of how team engagement in data-driven continuous learning is feasible at the frontline and can lead to higher job satisfaction and stronger teams. These types of team activities provide much-needed backbone to being a mature learning health system.
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Affiliation(s)
- Claire H. Robinson
- VA Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | | | | | - Laura J. Damschroder
- VA Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
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20
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Gray KE, Rao M, Gunnink E, Eschenroeder L, Geyer JR, Nelson KM, Reddy A. Home Telehealth in the Veterans Health Administration: Trends and Correlates of Length of Enrollment from 2010 to 2017. J Gen Intern Med 2022; 37:3089-3096. [PMID: 35230624 PMCID: PMC8886698 DOI: 10.1007/s11606-022-07452-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 02/03/2022] [Indexed: 10/26/2022]
Abstract
BACKGROUND Home telehealth (HT) programs enable communication and remote monitoring of patient health data between clinician visits, with the goal of improving chronic disease self-management and outcomes. The Veterans Health Administration (VHA) established one of the earliest HT programs in the country in 2003; however, little is known about how these services have been utilized and expanded over the last decade. OBJECTIVE To describe trends in use of VHA's HT program from 2010 through 2017 and correlates of length of enrollment in HT services. DESIGN Retrospective observational cohort study. PARTICIPANTS Patients enrolled in HT between January 1, 2010 and December 31, 2017. MAIN MEASURES We described the number and characteristics of patients enrolled in HT, including the chronic conditions managed. We also identified length of HT enrollment and examined patient and facility characteristics associated with longer enrollment. KEY RESULTS The total number of patients enrolled in HT was 402,263. At time of enrollment, half were >65 years old, 91% were male, and 59.3% lived in urban residences. The most common conditions addressed by HT were hypertension (28.8%), obesity (23.9%), and diabetes (17.0%). The median time to disenrollment in HT was 261 days (8.6 months) but varied by chronic condition. In a multivariable Cox proportional hazards model, covariates associated with higher likelihood of staying enrolled were older age, male gender, non-Hispanic Black race/ethnicity, lower neighborhood socioeconomic status, living in a more rural setting, and a greater burden of comorbidities per the Gagne index. CONCLUSIONS Across 8 years, over 400,000 veterans engaged in HT services for chronic disease management and over half remained in the program for longer than 8 months. Our work provides a real-world evaluation of HT service expansion in the VHA. Additional studies are necessary to identify optimal enrollment duration and patients most likely to benefit from HT services.
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Affiliation(s)
- Kristen E Gray
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Mayuree Rao
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA. .,General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA. .,Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA.
| | - Eric Gunnink
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Lee Eschenroeder
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - John R Geyer
- General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Karin M Nelson
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA.,General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Ashok Reddy
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA.,General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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21
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Gray KE, Hoerster KD, Spohr SA, Breland JY, Raffa SD. National Veterans Health Administration MOVE! Weight Management Program Participation During the COVID-19 Pandemic. Prev Chronic Dis 2022; 19:E11. [PMID: 35271436 PMCID: PMC8937622 DOI: 10.5888/pcd19.210303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction In response to COVID-19, the Veterans Health Administration (VHA) converted appropriate outpatient visits to virtual care, including MOVE! Weight Management Program for Veterans (MOVE!) visits. Before the pandemic, most veterans participated in MOVE! in person, with several telehealth modalities available. We sought to describe national trends in MOVE! participation during the pandemic (March 2020–January 2021) overall and by modality and to compare participation to prepandemic levels. Methods We conducted a national retrospective cohort study of veterans who participated in MOVE! from January 2018 through January 2021. We examined MOVE! participation across VHA aggregated at the national level by month, including the number of visits, participants, and new participants in person and via telehealth, including telephone, clinic-to-clinic synchronous video, anywhere-to-anywhere (eg, provider home to patient home) synchronous video, and remote education and monitoring. We also determined the percentage of all MOVE! visits attributable to each modality and the monthly percentage change in participation during the pandemic compared with monthly averages in prior years. Results Before March 2020, 20% to 30% of MOVE! was delivered via telehealth, which increased to 90% by April 2020. Early in the pandemic, telephone-delivered MOVE! was the most common modality, but anywhere-to-anywhere synchronous video participation increased over time. Compared with the same months in prior years, total monthly MOVE! participation remained 20% to 40% lower at the end of 2020 and into January 2021. Conclusion The VHA MOVE! program rapidly shifted to telehealth delivery of weight management services in response to the pandemic. However, a gap remained in the number of veterans receiving these services compared with prior years, suggesting potential unmet needs for weight management.
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Affiliation(s)
- Kristen E. Gray
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle Division, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, Washington
| | - Katherine D. Hoerster
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle Division, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, Washington
- Mental Health Service, VA Puget Sound Health Care System, Seattle Division, Seattle, Washington
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Stephanie A. Spohr
- National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Durham, North Carolina
| | - Jessica Y. Breland
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Susan D. Raffa
- National Center for Health Promotion and Disease Prevention, Veterans Health Administration, Durham, North Carolina
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
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22
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Cuevas AG, Cofie LE, Nolte S. The Association Between Veteran Status and Obesity Differs Across Race/Ethnicity. Am J Health Promot 2021; 36:314-317. [PMID: 34860589 DOI: 10.1177/08901171211052994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE This study aims to evaluate the interaction between veteran status and race/ethnicity on obesity status. DESIGN Cross-sectional survey. SETTING The 2013-2017 National Health Interview Survey. SAMPLE A total of 151,765 adults (8.62% veterans and 91.38 nonveterans) with 69.30% identifying as White, 13.05% identifying as Hispanic, 12.57% identifying as Black, and 5.08% identifying as Asian. MEASURES Obesity status (measured using self-reported body mass index), race/ethnicity, survey year, age, marital status, educational attainment, federal poverty level, health insurance, type of insurance, self-reported health status, and whether participant had a usual care source. ANALYSIS Weighted logistic regression analysis. RESULTS In a fully adjusted model, there was no evidence that veterans overall had higher odds of obesity compared to nonveterans (adjusted odd ratio (aOR): 1.05, 95% CI: .99, 1.11). White veterans had lower odds of obesity compared to White nonveterans (OR: .93, 95% CI: .87, .98). Hispanic veterans had higher odds of obesity compared to Hispanic nonveterans (aOR: 1.53, 95% CI: 1.23, 1.90). There was no evidence of an association between veteran status and obesity status for Black and Asian adults. CONCLUSIONS Effectual prevention strategies are needed to decrease obesity risks among active and retired Hispanic veterans.
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Affiliation(s)
- Adolfo G Cuevas
- Department of Community Health, Tufts University, Medford, MA, USA
| | - Leslie E Cofie
- Department of Health Education and Promotion, East Carolina University, Greenville, NC, USA
| | - Sarah Nolte
- Department of Health Education and Promotion, East Carolina University, Greenville, NC, USA
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23
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Tucker S, Bramante C, Conroy M, Fitch A, Gilden A, Wittleder S, Jay M. The Most Undertreated Chronic Disease: Addressing Obesity in Primary Care Settings. Curr Obes Rep 2021; 10:396-408. [PMID: 34297343 PMCID: PMC8300078 DOI: 10.1007/s13679-021-00444-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW While obesity-related comorbidities are frequently addressed and treated in primary care (PC), obesity itself is undertreated. We review the current treatments for obesity and provide potential provider and system-level strategies for integrating weight management and improving longer term obesity care within PC settings. RECENT FINDINGS We now understand that the body develops multiple mechanisms to resist weight loss and promote weight regain, making both weight loss and weight loss maintenance challenging. Therefore, weight management often requires medically supervised interventions and should be treated on a long-term basis. However, there are multiple barriers to improving obesity care within PC settings. Clinically, utilizing strategies such as a shared decision-making approach and the 5As to discuss treatment options can facilitate formulating an obesity treatment plan. Utilizing telehealth, a team-based approach, and community partnering can increase patient access to intensive behavioral interventions. Future studies should evaluate other cost-effective methods to implement obesity care into the PC setting.
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Affiliation(s)
- Shanna Tucker
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Carolyn Bramante
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
- Center for Pediatric Obesity Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Molly Conroy
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Angela Fitch
- Departments of Medicine and Surgery, Massachusetts General Hospital Weight Center, Harvard Medical School, Boston, MA, USA
| | - Adam Gilden
- Kaiser Permanente Colorado, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Sandra Wittleder
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Melanie Jay
- Departments of Medicine and Population Health, NYU Grossman School of Medicine, New York, NY, USA.
- New York Harbor Veterans Affairs, New York, NY, USA.
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24
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Lohnberg JA, Salcido L, Frayne S, Mahtani N, Bates C, Hauser ME, Breland JY. Rapid conversion to virtual obesity care in COVID-19: Impact on patient care, interdisciplinary collaboration, and training. Obes Sci Pract 2021; 8:131-136. [PMID: 34540265 PMCID: PMC8441727 DOI: 10.1002/osp4.550] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/09/2021] [Accepted: 07/26/2021] [Indexed: 12/14/2022] Open
Abstract
Objective The COVID‐19 pandemic presents challenges to maintaining interdisciplinary collaboration while transitioning care to telehealth environments. This paper describes how an intensive weight management clinic rapidly transitioned from in‐person only to a telehealth environment. Method As a program evaluation project, changes to clinic procedures were tracked on a weekly basis. Patients were invited to complete phone surveys after clinic appointments from 1 May 2020 to 31 July 2020. The survey included 12 items rated on a 5‐point scale (“strongly disagree” to “strongly agree”). Results Adaptations included converting team meetings and clinical training to phone/video platforms and transferring a complex patient tracking system to an interactive virtual format. Fifty‐eight patients completed phone surveys (81% response rate). All “agreed” or “strongly agreed” that they were satisfied with telehealth care; 51% “agreed” or “strongly agreed” that telephone visits were as good as in‐person visits; and 53% preferred phone appointments even after pandemic restrictions are eased. Conclusions It is feasible to rapidly transition to a telehealth clinic when supported by infrastructure and resources of a national, integrated healthcare system. Patient preferences include access to both telehealth and in‐person services. A blended telehealth/in‐person model that maintains interdisciplinary collaboration and training is necessary even after the COVID‐19 pandemic.
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Affiliation(s)
- Jessica A Lohnberg
- Psychology Service Veterans Affairs Palo Alto Health Care System Palo Alto California USA.,Department of Psychiatry & Behavioral Sciences Stanford University School of Medicine Stanford California USA
| | - Lianne Salcido
- Psychology Service Veterans Affairs Palo Alto Health Care System Palo Alto California USA
| | - Susan Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i) VA Palo Alto Health Care System Menlo Park California USA.,Division of Primary Care and Population Health Stanford University Stanford California USA
| | - Naina Mahtani
- Mental Health Service San Francisco VA Health Care System San Francisco California USA
| | - Cheryl Bates
- Medical Service Veterans Affairs Palo Alto Health Care System Palo Alto California USA
| | - Michelle E Hauser
- Division of Primary Care and Population Health Stanford University Stanford California USA.,Medical Service Veterans Affairs Palo Alto Health Care System Palo Alto California USA.,Minimally Invasive & Bariatric Surgery Division of General Surgery Department of Surgery Stanford University School of Medicine Stanford California USA.,Department of Medicine Adult Primary Care-Fair Oaks Health Center San Mateo County Health System Redwood City California USA
| | - Jessica Y Breland
- Department of Psychiatry & Behavioral Sciences Stanford University School of Medicine Stanford California USA.,VA HSR&D Center for Innovation to Implementation (Ci2i) VA Palo Alto Health Care System Menlo Park California USA
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25
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Funk LM, Breuer CR, Venkatesh M, Muraveva A, Alagoz E, Hanlon BM, Raffa SD, Voils CI. Protocol and short-term results for a feasibility randomized controlled trial of a video intervention for Veterans with obesity: The TOTAL (Teaching Obesity Treatment Options to Adult Learners) pilot study. Contemp Clin Trials Commun 2021; 23:100816. [PMID: 34258469 PMCID: PMC8256180 DOI: 10.1016/j.conctc.2021.100816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 06/18/2021] [Accepted: 06/27/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction All three evidence-based treatment options for adults with severe obesity – behavioral weight management, weight management medications (WMM), and bariatric surgery – are underutilized in the Veterans Health Administration (VHA) system. Our objective in this study was to develop and pilot-test the TOTAL (Teaching Obesity Treatment Options to Adult Learners) intervention, which seeks to increase Veteran participation in obesity treatment. Methods In this single-site, parallel, pilot RCT, Veterans with severe obesity with an upcoming behavioral weight management visit were sent a recruitment letter after meeting inclusion/exclusion criteria via electronic health record screening. Eligible Veterans were randomized to TOTAL or usual care. TOTAL consisted of an 18-min video highlighting obesity health risks and treatment outcomes, eligibility criteria, and pros/cons of all three evidence-based obesity treatments. The primary outcomes were trial design feasibility (recruitment and retention rates) and acceptability to Veterans, which was assessed via semi-structured interviews with participants one week after randomization to TOTAL. Secondary outcomes included attitudes and self-efficacy to initiate treatment one week post-randomization and BMI change six months post-randomization (assessed via Cohen's d). Results Forty-two Veterans were randomized (recruitment rate = 47.2%), and 40/42 completed one-week assessments (retention rate = 95.2%). The mean participant age was 59.2 ± 11.9 years. Female and non-White participants comprised 14.3% and 11.9% of the cohort, respectively. Semi-structured interviews with all 20 participants who received TOTAL suggested that the delivery logistics and content of TOTAL were acceptable to Veterans. Attitudes toward behavioral weight management and bariatric surgery and weight loss improved in TOTAL vs. usual care patients (Cohen's d ranging from 0.3 to 0.6). Conclusions TOTAL was feasible to implement, acceptable to Veterans, and has the potential to increase obesity treatment participation in VHA. An adequately powered RCT is warranted to assess its impact on population-level weight loss. Trial registration ClinicalTrials.gov NCT03856320.
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Affiliation(s)
- Luke M Funk
- Department of Surgery, William S. Middleton VA, Madison, WI, USA.,Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Manasa Venkatesh
- Department of Surgery, William S. Middleton VA, Madison, WI, USA
| | - Anna Muraveva
- Department of Surgery, William S. Middleton VA, Madison, WI, USA
| | - Esra Alagoz
- Department of Surgery, William S. Middleton VA, Madison, WI, USA
| | - Bret M Hanlon
- Department of Surgery, William S. Middleton VA, Madison, WI, USA.,Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | - Susan D Raffa
- Department of Veterans Affairs, National Center for Health Promotion and Disease Prevention, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, USA
| | - Corrine I Voils
- Department of Surgery, William S. Middleton VA, Madison, WI, USA.,Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
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Hoerster KD, Tanksley L, Sulayman N, Bondzie J, Brier M, Damschroder L, Coggeshall S, Houseknecht D, Hunter-Merrill R, Monty G, Saelens BE, Sayre G, Simpson T, Wong E, Nelson K. Testing a tailored weight management program for veterans with PTSD: The MOVE! + UP randomized controlled trial. Contemp Clin Trials 2021; 107:106487. [PMID: 34144246 DOI: 10.1016/j.cct.2021.106487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Katherine D Hoerster
- VA Puget Sound Healthcare System, Seattle Division, Mental Health Service; 1660 South Columbian Way (S-116), Seattle, WA 98108, United States; VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; University of Washington, Department of Psychiatry and Behavioral Sciences, 100 NE 45(th) Street, Suite 300, Seattle, WA 98105; United States.
| | - Lamont Tanksley
- VA Puget Sound Healthcare System, Seattle Division, Mental Health Service; 1660 South Columbian Way (S-116), Seattle, WA 98108, United States.
| | - Nadiyah Sulayman
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Juliana Bondzie
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Moriah Brier
- VA Puget Sound Healthcare System, Anesthesiology Service, 1660 South Columbian Way, Seattle, WA 98108, United States.
| | - Laura Damschroder
- VA Ann Arbor Center for Clinical Management Research, 2800 Plymouth Rd. NCRC Bldg 16 (152), Ann Arbor, MI 48105, USA.
| | - Scott Coggeshall
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Dakota Houseknecht
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Rachel Hunter-Merrill
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Gillian Monty
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Brian E Saelens
- Seattle Children's Research Institute, 1920 Terry Avenue, Seattle, WA 98101, United States of America; University of Washington, Department of Pediatrics, 1959 NE Pacific Street, Seattle, WA 98195, United States of America.
| | - George Sayre
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; VA Puget Sound Health Care System, Center of Excellence in Substance Addiction Treatment and Education (CESATE), 1660 South Columbian Way, Seattle, WA 98108, United States; University of Washington, School of Public Health, Department of Health Services, United States.
| | - Tracy Simpson
- VA Puget Sound Healthcare System, Seattle Division, Mental Health Service; 1660 South Columbian Way (S-116), Seattle, WA 98108, United States; VA Puget Sound Health Care System, Center of Excellence in Substance Addiction Treatment and Education (CESATE), 1660 South Columbian Way, Seattle, WA 98108, United States; University of Washington, School of Public Health, Department of Health Services, United States.
| | - Edwin Wong
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Karin Nelson
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; VA Puget Sound Health Care System, Center of Excellence in Substance Addiction Treatment and Education (CESATE), 1660 South Columbian Way, Seattle, WA 98108, United States; University of Washington, School of Public Health, Department of Health Services, United States; University of Washington, Department of Medicine, 1959 NE Pacific St, Seattle, WA 98195, United States.
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Nutrition and physical activity interventions for the general population with and without cardiometabolic risk: a scoping review. Public Health Nutr 2021; 24:4718-4736. [PMID: 34030758 DOI: 10.1017/s1368980021002184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The objective of this scoping review was to examine the research question: In the adults with or without cardiometabolic risk, what is the availability of literature examining interventions to improve or maintain nutrition and physical activity-related outcomes? Sub-topics included: (1) behaviour counseling or coaching from a dietitian/nutritionist or exercise practitioner, (2) mobile applications to improve nutrition and physical activity and (3) nutritional ergogenic aids. DESIGN The current study is a scoping review. A literature search of the Medline Complete, CINAHL Complete, Cochrane Database of Systematic Reviews and other databases was conducted to identify articles published in the English language from January 2005 until May 2020. Data were synthesised using bubble charts and heat maps. SETTING Out-patient, community and workplace. PARTICIPANTS Adults with or without cardiometabolic risk factors living in economically developed countries. RESULTS Searches resulted in 19 474 unique articles and 170 articles were included in this scoping review, including one guideline, thirty systematic reviews (SR), 134 randomised controlled trials and five non-randomised trials. Mobile applications (n 37) as well as ergogenic aids (n 87) have been addressed in several recent studies, including SR. While primary research has examined the effect of individual-level nutrition and physical activity counseling or coaching from a dietitian/nutritionist and/or exercise practitioner (n 48), interventions provided by these practitioners have not been recently synthesised in SR. CONCLUSION SR of behaviour counseling or coaching provided by a dietitian/nutritionist and/or exercise practitioner are needed and can inform practice for practitioners working with individuals who are healthy or have cardiometabolic risk.
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Liu N, Venkatesh M, Hanlon BM, Muraveva A, Johnson MK, Hanrahan LP, Funk LM. Association Between Medicaid Status, Social Determinants of Health, and Bariatric Surgery Outcomes. ANNALS OF SURGERY OPEN 2021; 2:e028. [PMID: 33912867 PMCID: PMC8059876 DOI: 10.1097/as9.0000000000000028] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/19/2020] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE To compare outcomes after bariatric surgery between Medicaid and non-Medicaid patients and assess whether differences in social determinants of health were associated with postoperative weight loss. BACKGROUND The literature remains mixed on weight loss outcomes and healthcare utilization for Medicaid patients after bariatric surgery. It is unclear if social determinants of health geocoded at the neighborhood level are associated with outcomes. METHODS Patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from 2008 to 2017 and had ≥1 year of follow-up within a large health system were included. Baseline characteristics, 90-day and 1-year outcomes, and weight loss were compared between Medicaid and non-Medicaid patients. Area deprivation index (ADI), urbanicity, and walkability were analyzed at the neighborhood level. Median regression with percent total body weight (TBW) loss as the outcome was used to assess predictors of weight loss after surgery. RESULTS Six hundred forty-seven patients met study criteria (191 Medicaid and 456 non-Medicaid). Medicaid patients had a higher 90-day readmission rate compared to non-Medicaid patients (19.9% vs 12.3%, P < 0.016). Weight loss was similar between Medicaid and non-Medicaid patients (23.1% vs 21.9% TBW loss, respectively; P = 0.266) at a median follow-up of 3.1 years. In adjusted analyses, Medicaid status, ADI, urbanicity, and walkability were not associated with weight loss outcomes. CONCLUSIONS Medicaid status and social determinants of health at the neighborhood level were not associated with weight loss outcomes after bariatric surgery. These findings suggest that if Medicaid patients are appropriately selected for bariatric surgery, they can achieve equivalent outcomes as non-Medicaid patients.
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Affiliation(s)
- Natalie Liu
- From the Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Manasa Venkatesh
- From the Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Bret M. Hanlon
- From the Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Anna Muraveva
- From the Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Morgan K. Johnson
- From the Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Lawrence P. Hanrahan
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Luke M. Funk
- From the Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
- William S. Middleton Memorial Veterans Administration, Madison, WI
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The LEAP Program: Quality Improvement Training to Address Team Readiness Gaps Identified by Implementation Science Findings. J Gen Intern Med 2021; 36:288-295. [PMID: 32901440 PMCID: PMC7878618 DOI: 10.1007/s11606-020-06133-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 08/11/2020] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Katherine D Hoerster
- Seattle Division, Health Services Research & Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Kristen Gray
- Seattle Division, Health Services Research & Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington School of Public Health, Seattle
| | - Susan D Raffa
- Veterans Affairs National Center for Health Promotion and Disease Prevention, Durham, North Carolina.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
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Hoerster KD, Collins MP, Au DH, Lane A, Epler E, McDowell J, Barón AE, Rise P, Plumley R, Nguyen T, Schooler M, Schuttner L, Ma J. Testing a self-directed lifestyle intervention among veterans: The D-ELITE pragmatic clinical trial. Contemp Clin Trials 2020; 95:106045. [PMID: 32473403 PMCID: PMC7253950 DOI: 10.1016/j.cct.2020.106045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/12/2020] [Accepted: 05/25/2020] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Katherine D Hoerster
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; VA Puget Sound Healthcare System, Seattle Division, Mental Health Service, 1660 South Columbian Way (S-116), Seattle, WA 98108, United States; University of Washington, Department of Psychiatry and Behavioral Sciences, 1100 NE 45(th) Street, Suite 300, Seattle, WA 98105, United States.
| | - Margaret P Collins
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - David H Au
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; University of Washington, Department of Medicine, 1959 NE Pacific St, Seattle, WA 98195, United States.
| | - Amber Lane
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Eric Epler
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Jennifer McDowell
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Anna E Barón
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, 13001 E. 17(th) Place, Aurora, CO 80045, United States.
| | - Peter Rise
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Robert Plumley
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Tanya Nguyen
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Mary Schooler
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Linnaea Schuttner
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; University of Washington, Department of Medicine, 1959 NE Pacific St, Seattle, WA 98195, United States.
| | - Jun Ma
- University of Illinois at Chicago, Department of Medicine, 1747 W. Roosevelt Rd, Room 586 (MC 275), Chicago, IL 60608, United States.
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Annis A, Freitag MB, Evans RR, Wiitala WL, Burns J, Raffa SD, Spohr SA, Damschroder LJ. Construction and Use of Body Weight Measures from Administrative Data in a Large National Health System: A Systematic Review. Obesity (Silver Spring) 2020; 28:1205-1214. [PMID: 32478469 PMCID: PMC7384104 DOI: 10.1002/oby.22790] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 01/29/2020] [Accepted: 02/11/2020] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Ann Annis
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
- College of NursingMichigan State UniversityEast LansingMichiganUSA
| | - Michelle B. Freitag
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Richard R. Evans
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Wyndy L. Wiitala
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Jennifer Burns
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Susan D. Raffa
- National Center for Health Promotion and Disease PreventionVeterans Health AdministrationDurhamNorth CarolinaUSA
- Department of Psychiatry & Behavioral SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Stephanie A. Spohr
- National Center for Health Promotion and Disease PreventionVeterans Health AdministrationDurhamNorth CarolinaUSA
| | - Laura J. Damschroder
- Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichiganUSA
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Cuthbert K, Hardin S, Zelkowitz R, Mitchell K. Eating Disorders and Overweight/Obesity in Veterans: Prevalence, Risk Factors, and Treatment Considerations. Curr Obes Rep 2020; 9:98-108. [PMID: 32361915 DOI: 10.1007/s13679-020-00374-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Eating disorders (EDs) and overweight/obesity (OW/OB) have a significant impact on veterans. This review highlights current research on EDs and OW/OB in this population. RECENT FINDINGS Prevalence estimates for both EDs and OW/OB among veterans remain consistent with and possibly higher than those in the general population. Both diagnoses share multiple risk factors, including trauma history, and mental health comorbidities. Although weight loss treatments have been fairly well studied among veteran samples, there are no published investigations on psychotherapies for EDs in this population. The Veterans Healthcare Administration is working to train providers in ED treatments. VHA treatments for OW/OB show some benefits and areas for improvement. Areas for future research include structured assessments for EDs and disordered eating behaviors in veterans to clarify prevalence estimates. There is a need for interventions that consider common mechanisms for ED and OW/OB, and there is a need for more research on the associations between different types of trauma and ED/OW/OB in veterans.
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Affiliation(s)
- Kristy Cuthbert
- Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA
- National Center for PTSD at the VA Boston Healthcare System, Boston, MA, 02130, USA
| | - Sabrina Hardin
- National Center for PTSD at the VA Boston Healthcare System, Boston, MA, 02130, USA
| | - Rachel Zelkowitz
- National Center for PTSD at the VA Boston Healthcare System, Boston, MA, 02130, USA
| | - Karen Mitchell
- National Center for PTSD at the VA Boston Healthcare System, Boston, MA, 02130, USA.
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA.
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Graham LA, Malone EB, Richman JS, Carson AP, Affuso O, Knight SJ, Levitan EB. Association of Food Access, Recreational Opportunities, and Natural Amenities with Engagement in the Veterans MOVE! Weight Management Program. Obesity (Silver Spring) 2020; 28:55-64. [PMID: 31858739 PMCID: PMC6973238 DOI: 10.1002/oby.22640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 08/11/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The aim of this study was to examine the association of county-level food access, recreational opportunities, and natural amenities with participant engagement in a weight management program. METHODS In this cohort study, participants in the Veterans Health Administration MOVE! weight management program between October 1, 2007, and September 30, 2013, were observed for 12 months after enrollment. Engagement was measured as the number of program visits per year at 12 months. Cross-sectional analysis and spatial regression were used to examine county characteristics associated with greater participant engagement at 12 months. RESULTS A total of 321,624 participants in 2,708 counties were included. Greater engagement was associated with older age, female sex, white race, being married, and being retired. After accounting for similarities between nearby communities, engagement at 12 months was 3.1 visits higher for each additional farmers' market per 1,000 population (P = 0.01). Engagement was highest for participants living in counties with the most natural amenities (P < 0.001). Recreational opportunities had only a small effect on engagement in the program (β = 0.02 visits at 12 months; P = 0.002). CONCLUSIONS Consideration of a participant's county characteristics in addition to other known demographics and program factors may help to explain variation in engagement in weight management programs.
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Affiliation(s)
- Laura A. Graham
- Department of Epidemiology, School of Public HealthUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Emily B. Malone
- Department of Epidemiology, School of Public HealthUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Joshua S. Richman
- Division of Gastrointestinal Surgery, Department of SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - April P. Carson
- Department of Epidemiology, School of Public HealthUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Olivia Affuso
- Department of Epidemiology, School of Public HealthUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Sara J. Knight
- Division of Gastrointestinal Surgery, Department of SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Division of Preventive Medicine, School of MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Emily B. Levitan
- Department of Epidemiology, School of Public HealthUniversity of Alabama at BirminghamBirminghamAlabamaUSA
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Zenk SN, Tarlov E, Wing C, Slater S, Jones KK, Fitzgibbon M, Powell LM. Does the built environment influence the effectiveness of behavioral weight management interventions? Prev Med 2019; 126:105776. [PMID: 31330154 PMCID: PMC6878977 DOI: 10.1016/j.ypmed.2019.105776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 06/01/2019] [Accepted: 07/14/2019] [Indexed: 11/28/2022]
Abstract
Outcomes of behavioral lifestyle interventions for promoting weight loss vary widely across participants. The effectiveness of a weight management intervention may depend on a person's environmental context. This study compared short- and longer-term effects of a structured nationwide weight management program for people living in neighborhoods with different levels of walkability and different access to recreational places (parks, fitness facilities). Drawing on the health production model, we tested competing hypotheses for whether treatment effects of the program complement environmental supports or substitute for environmental constraints. We studied the US Department of Veterans Affairs (VA) MOVE! weight management program using VA electronic heath record data (2009-2014) and a difference-in-differences design with an inverse propensity score matched comparison group. A total of 114,256 program participants and 498,494 non-participants comprised the sample. Built environment features were measured within one-mile of each person's home. We estimated program effects on body mass index (BMI) for subgroups with different built environments at 6-, 12-, 18-, and 24-month follow-up using linear regressions with person and year fixed effects. At 6 months, the program reduced BMI by 0.4-0.6 kg/m2 among men and 0.3-0.5 kg/m2 among women. The effect diminished at 12, 18, and 24 months. The program effect did not vary significantly across subgroups with different walkability, park access, or fitness facility access. The MOVE! program was not sensitive to environmental context. Results did not lend support to either hypothesis that the MOVE! program complements or substitutes for a person's built environment to affect weight management outcomes.
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Affiliation(s)
- Shannon N Zenk
- University of Illinois at Chicago College of Nursing, 845 S. Damen Ave., Chicago, IL 60612, USA.
| | - Elizabeth Tarlov
- University of Illinois at Chicago College of Nursing, 845 S. Damen Ave., Chicago, IL 60612, USA; Edward Hines Jr. Veterans Affairs Hospital, Hines, IL 60141, USA.
| | - Coady Wing
- Indiana University School of Public and Environmental Affairs, Bloomington, IN 47405, USA.
| | - Sandy Slater
- University of Illinois at Chicago College of Nursing, 845 S. Damen Ave., Chicago, IL 60612, USA; University of Illinois at Chicago School of Public Health, Chicago, IL 60612, USA.
| | - Kelly K Jones
- University of Illinois at Chicago College of Nursing, 845 S. Damen Ave., Chicago, IL 60612, USA.
| | - Marian Fitzgibbon
- University of Illinois at Chicago Institute for Health Research and Policy, Chicago, IL 60612, USA; University of Illinois at Chicago Department of Pediatrics, Chicago, IL 60612, USA.
| | - Lisa M Powell
- University of Illinois at Chicago Institute for Health Research and Policy, Chicago, IL 60612, USA; University of Illinois at Chicago School of Public Health, Chicago, IL 60612, USA.
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Powell LM, Jones K, Duran AC, Tarlov E, Zenk SN. The price of ultra-processed foods and beverages and adult body weight: Evidence from U.S. veterans. ECONOMICS AND HUMAN BIOLOGY 2019; 34:39-48. [PMID: 31204255 PMCID: PMC6897320 DOI: 10.1016/j.ehb.2019.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 05/22/2019] [Accepted: 05/28/2019] [Indexed: 05/02/2023]
Abstract
The consumption of ultra-processed foods in the U.S. and globally has increased and is associated with lower diet quality, higher energy intake, higher body weight, and poorer health outcomes. This study drew on individual-level data on measured height and weight from U.S. Department of Veterans Affairs medical records for adults aged 20 to 64 from 2009 through 2014 linked to food and beverage price data from the Council for Community and Economic Research to examine the association between the price of ultra-processed foods and beverages and adult body mass index (BMI). We estimated geographic fixed effects models to control for unobserved heterogeneity of prices. We estimated separate models for men and women and we assessed differences in price sensitivity across subpopulations by socioeconomic status (SES). The results showed that a one-dollar increase in the price of ultra-processed foods and beverages was associated with 0.08 lower BMI units for men (p ≤ 0.05) (price elasticity of BMI of -0.01) and 0.14 lower BMI units for women (p ≤ 0.10) (price elasticity of BMI of -0.02). Higher prices of ultra-processed foods and beverages were associated with lower BMI among low-SES men (price elasticity of BMI of -0.02) and low-SES women (price elasticity of BMI of -0.07) but no statistically significant associations were found for middle- or high-SES men or women. Robustness checks based on the estimation of an individual-level fixed effects model found a consistent but smaller association between the price of ultra-processed foods and beverages and BMI among women (price elasticity of BMI of -0.01) with a relatively larger association for low-SES women (price elasticity of BMI of -0.04) but revealed no association for men highlighting the importance of accounting for individual-level unobserved heterogeneity.
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Affiliation(s)
- Lisa M Powell
- Health Policy and Administration, School of Public Health, University of Illinois at Chicago, United States.
| | - Kelly Jones
- Health Systems Science, College of Nursing, University of Illinois at Chicago, United States
| | | | - Elizabeth Tarlov
- College of Nursing, University of Illinois at Chicago, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, United States
| | - Shannon N Zenk
- Health Systems Science, College of Nursing, University of Illinois at Chicago
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Wischik DL, Magny-Normilus C, Whittemore R. Risk Factors of Obesity in Veterans of Recent Conflicts: Need for Diabetes Prevention. Curr Diab Rep 2019; 19:70. [PMID: 31368008 PMCID: PMC7530827 DOI: 10.1007/s11892-019-1191-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW To identify factors associated with obesity in veterans of the recent, Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) war conflicts. RECENT FINDINGS Over 44% OEF/OIF/OND veterans are obese (BMI > 30 kg/m2), which exceeds the national obesity prevalence rate of 39% in people younger than 45. Obesity increases morbidity, risk for type 2 diabetes (T2D), and mortality as well as decreases quality of life. A scoping review method was used to identify factors associated with obesity in young veterans. Military exposures, such as multiple deployments and exposure to combat, contribute to challenges in re-integration to civilian life in all veterans. Factors that contribute to increased risk for obesity include changes in eating patterns/eating disorders, changes in physical activity, physical disability, and psychological comorbidity. These conditions can contribute to a rapid weight gain trajectory, changes in metabolism, and obesity. Young veterans face considerable challenges related to obesity risk. Further research is needed to better understand young veterans' experiences and health needs in order to adapt or expand existing programs and improve access, engagement, and metabolic outcomes in this vulnerable population.
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Affiliation(s)
| | | | - Robin Whittemore
- Yale School of Nursing, 400 West Campus Drive, Orange, CT, 06477, USA
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Vasudevan V, Bouldin E, Bloodworth S, Rocafort L. Likelihood of Meeting Physical Activity Guidelines of Veterans Who Are Obese by Disability Status. Am J Health Promot 2019; 33:1194-1199. [PMID: 31284722 DOI: 10.1177/0890117119861565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
| | - Erin Bouldin
- Department of Health and Exercise Science, Appalachian State University, Boone, NC, USA
| | - Shannon Bloodworth
- North Florida (NF)/South Georgia (SG) Veterans Health System, Gainesville, FL, USA
| | - Linda Rocafort
- North Florida (NF)/South Georgia (SG) Veterans Health System, Gainesville, FL, USA
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Thomas DD, Waring ME, Ameli O, Reisman JI, Vimalananda VG. Patient Characteristics Associated with Receipt of Prescription Weight-Management Medications Among Veterans Participating in MOVE! Obesity (Silver Spring) 2019; 27:1168-1176. [PMID: 31090207 PMCID: PMC6591039 DOI: 10.1002/oby.22503] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/15/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Weight-management medications (WMM) are recommended for the treatment of obesity. This study examined characteristics associated with initial receipt of WMM among eligible veterans in the first year following enrollment in the Veterans Health Administration (VHA) MOVE! behavioral weight-management program. METHODS We conducted a retrospective cohort study of VHA patients with obesity or overweight and obesity-related comorbidities who enrolled in MOVE! from October 2013 to September 2016 (N = 153,939). Multivariable logistic regression models estimated predictors of having a filled prescription for WMM and for orlistat. RESULTS A total of 1.1% of these veterans received WMM. The most common WMM included orlistat (70.4%), phentermine/topiramate (11.2%), and bupropion/naltrexone (9.7%). Female sex, higher BMI, obstructive sleep apnea, osteoarthritis, depression, lower back pain, and alcohol abuse were associated with greater odds of use of WMM, whereas age over 65 years, Hispanic ethnicity, and required co-payments were associated with lower odds. Among patients receiving WMM, older age, black race, female sex, higher BMI, cardiovascular disease, lower back pain, and congestive heart failure were associated with use of orlistat versus any other WMM. CONCLUSIONS Of patients engaged in MOVE! in the VHA, 1.1% received WMM. WMM are underutilized among veterans. Additional research is needed to understand barriers to incorporating WMM into comprehensive obesity treatment plans.
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Affiliation(s)
- Dylan D. Thomas
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine; Boston University School of Medicine. Boston, MA
| | - Molly E. Waring
- Department of Allied Health Sciences, University of Connecticut. Storrs, CT
| | - Omid Ameli
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Affairs Medical Center. Bedford, MA
| | - Joel I. Reisman
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Affairs Medical Center. Bedford, MA
| | - Varsha G. Vimalananda
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Department of Medicine; Boston University School of Medicine. Boston, MA
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Affairs Medical Center. Bedford, MA
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Maciejewski ML, Arterburn DE, Berkowitz TSZ, Weidenbacher HJ, Liu CF, Olsen MK, Funk LM, Mitchell JE, Smith VA. Geographic Variation in Obesity, Behavioral Treatment, and Bariatric Surgery for Veterans. Obesity (Silver Spring) 2019; 27:161-165. [PMID: 30421849 PMCID: PMC6309247 DOI: 10.1002/oby.22350] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/28/2018] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Matthew L Maciejewski
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Theodore S Z Berkowitz
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Hollis J Weidenbacher
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Chuan-Fen Liu
- Center for Health Services Research in Older Adults, Puget Sound Health Care System, Seattle, Washington, USA
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Maren K Olsen
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Luke M Funk
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - James E Mitchell
- Department of Psychiatry and Behavioral Science, University of North Dakota, Fargo, North Dakota, USA
| | - Valerie A Smith
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
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McKinnon CR, Garvin JT. Weight Reduction Goal Achievement Among Veterans With Mental Health Diagnoses. J Am Psychiatr Nurses Assoc 2019; 25:257-265. [PMID: 30239250 DOI: 10.1177/1078390318800594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Caroline R McKinnon
- 1 Caroline R. McKinnon, PhD, CNS/PMH-BC, Augusta University College of Nursing, Augusta, GA, USA
| | - Jane T Garvin
- 2 Jane T. Garvin, PhD, APRN, FNP-BC, University of St. Augustine for Health Sciences, St. Augustine, FL, USA
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Tarlov E, Wing C, Gordon HS, Matthews SA, Jones KK, Powell LM, Zenk SN. Does Effectiveness of Weight Management Programs Depend on the Food Environment? Health Serv Res 2018; 53:4268-4290. [PMID: 30246454 DOI: 10.1111/1475-6773.13043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To estimate the causal effects of a population-scale behavioral weight management program and to determine whether the program's effectiveness depends on participants' geographic access to places to purchase healthy and less healthy foods. DATA SOURCES Secondary data from U.S. Department of Veterans Affairs clinical and administrative records (2008-2014), retail food environment measures from commercial databases (2008-2014), and the American Community Survey (2009-2014). STUDY DESIGN We estimated the effect of the VA's MOVE! weight management program on body mass index after 6 months using difference-in-difference regressions to compare participants with a propensity score-matched control group. We estimated treatment effects overall and in subgroups with different access to supermarkets, fast-food restaurants, and convenience stores. PRINCIPAL FINDINGS MOVE! reduced BMI by about 0.71 units among men and 0.70 units among women. The program was slightly less effective for men living near fast-food restaurants or convenience stores. We found no evidence that treatment effects varied with the food environment among women. CONCLUSIONS The residential food environment modestly alters MOVE! effectiveness among men. A greater understanding of environmental barriers to and facilitators of intentional weight loss is needed. This study highlights important potential intersections between health care and the community.
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Affiliation(s)
- Elizabeth Tarlov
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL.,College of Nursing, University of Illinois at Chicago, Chicago, IL
| | - Coady Wing
- School of Public and Environmental Affairs, Indiana University Bloomington, Bloomington, IN
| | - Howard S Gordon
- Jesse Brown VA Medical Center, Chicago, IL.,College of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Stephen A Matthews
- Department of Sociology and Criminology and Department of Anthropology, The Pennyslvania State University, University Park, PA
| | - Kelly K Jones
- College of Nursing, University of Illinois at Chicago, Chicago, IL
| | - Lisa M Powell
- School of Public Health, University of Illinois at Chicago, Chicago, IL
| | - Shannon N Zenk
- College of Nursing, University of Illinois at Chicago, Chicago, IL
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