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Spotlight on Obesity

May 2020

Introduction

In 2014, VA estimated that 78% of Veterans were overweight or obese1. Obesity is a risk factor for heart disease, type 2 diabetes, stroke, and some types of cancer. Diabetes and obesity have become a very prevalent combination2. While obesity is not considered by VA to be a service-connected disability, thus not considered directly related to military service for compensation purposes3, VA is committed to treating this condition.

Resulting from a combination of genetic, behavioral, and environmental factors, obesity and weight loss treatment is complex and requires research to identify optimal practices. Behaviors such as dietary patterns, physical activity, and medication use, plus societal factors such as education, socioeconomic status, and food marketing all must be considered.

Recent accomplishments in VA obesity research include reporting key findings on “hunger hormone” ghrelin, findings revealing that Veterans with PTSD and depression are at particular risk for obesity, advances in increased longevity through bariatric surgery, the discovery that as fat cells develop, they change the types of nutrients they metabolize, and the implementation of the MOVE! National program4. Following are examples of HSR&D’s continued research into effective obesity and weight loss treatment.

Self-directed Lifestyle Intervention: (D-ELITE)

Self-directed Lifestyle Intervention: (D-ELITE)

© iStock/adamkaz

Impact: The DELITE trial has potential to provide the evidence needed for deciding whether a low-cost, low-technology, self-directed program can be used to expand the treatment of obesity to a population-based level by improving access to obesity treatment regardless of Veteran place of residence.

Most Veterans who receive VA healthcare have obesity (41%) or are classified as overweight (37%), putting them at higher risk for multiple serious chronic health conditions. Providing evidence-based behavioral weight management programs to Veterans with obesity is a priority for the VA National Center for Health Promotion and Disease Prevention (NCP). While the VA NCP's MOVE! program—primarily delivered with in-person group visits—helps Veterans with obesity lose weight, its reach has been limited because of various barriers to care. Some Veterans may do better with a program they can complete from home at their own pace. In this trial, study investigators are examining the effectiveness among Veterans of a previously proven self-directed lifestyle intervention (called DVD Lifestyle Intervention (D-ELITE)) that targets modest, clinically meaningful weight loss over the course of a year using recorded video lessons (DVD or online streaming), written self-study aids, and optional lifestyle coaching. The study will compare participants randomly assigned to receive D-ELITE to those continuing in usual care on weight and self-reported general physical health status, one year after enrollment. Secondary outcomes include weight and general physical health status two years after enrollment; and obesity-related biometric measures and self-report psychological and behavioral factors such as physical activity and sleep quality, at one and two years following enrollment.

Veterans with obesity living in the western US were identified using the VA Corporate Data Warehouse (CDW), recruited to participate, and randomly assigned to receive the study intervention or usual care alone. The study uses CDW to assess weight change and biometric outcomes. To assess self-reported outcomes, participants completed questionnaires at baseline, and 12 months after randomization, and are currently completing 24-month follow-up questionnaires. The D-ELITE intervention focuses on gradual lifestyle behavior change aimed at improving eating habits and increasing physical activity.  It encourages participants to gradually achieve and maintain a 5-10% loss of baseline body weight and at least 150 minutes of moderate-intensity physical activity, such as brisk walking, each week. Participants watch one video, complete corresponding written self-guided learning materials, and track food intake and physical activity each week for the first 12 weeks, then work through 10 additional written handouts and continue food and activity tracking for the next nine months. Intervention participants have access to a lifestyle coach, as desired, for the full 12-month intervention period. In addition to patient outcomes, this study will examine the cost of delivering the intervention, information relevant to decision-makers and potential future dissemination. Evidence-based programs like this, which can be delivered remotely and with likely minimal resources required from the VA healthcare system, are greatly needed, especially now as the SARS-CoV-2 pandemic has required VA to rapidly transition to providing more remotely delivered care.

Preliminary Findings:

  • Recruitment: 511 Veterans were recruited and completed baseline surveys
  • 12-month outcomes: 420 CDW weights (82%) and 412 surveys (80%) completed
  • 24-month outcomes commenced in 02/2020 and will be completed 03/2021.
  • Analyses: Preparing for 12-month outcomes analysis

Principal Investigator: Katherine Hoerster, PhD MPH, is an investigator at the HSR&D Center of Innovation (COIN) for Veteran-Centered and Value-Driven Care and a clinician with the VA Puget Sound Seattle Division PTSD Clinical Team at the VA Puget Sound Health Care System, Seattle, WA. She is Assistant Professor in the University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences.


Stay Strong: A physical activity program for Afghanistan and Iraq Veterans

Stay Strong: A physical activity program for Afghanistan and Iraq Veterans

© iStock/Prostock-Studio

Impact: If successful, the Stay Strong program could be implemented as a national program to augment VA's current panel of options for OEF/OIF Veterans who need support to maintain a healthy lifestyle and prevent future disease.

Veterans from Afghanistan and Iraq (OEF/OIF) are at high risk for becoming overweight and obese. One study reported that 86% were overweight or obese at their first visit to a VA clinician. However, existing on-site VA programs are not necessarily designed for younger Veterans who may be more comfortable with technology-mediated interventions, and who may not yet have developed obesity-related chronic diseases. Additionally, OEF/OIF Veterans include a relatively high percentage of women compared to previous Veteran cohorts. These differences should be considered when designing and customizing lifestyle interventions for OEF/OIF Veterans.

Technology-mediated mobile health (mHealth) lifestyle interventions that include continuous, objective home monitoring of physical activity, automated internet-mediated feedback, and e-coaching can increase physical activity and improve weight loss in non-Veteran populations. When delivered on a large scale, mHealth interventions represent potential low cost and effective alternatives to face-to-face lifestyle change interventions. The VA health care system is in a unique position to implement such interventions on a national scale because of existing structures such as a national electronic medical records system. In addition to being able to quickly identify those who can benefit from such interventions, they can be centrally administered and marketed directly to Veterans, capitalizing on economies of scale, expanding intervention reach, and reducing the burden of recruitment on the existing health care team. However, with the exception of one pilot study, prevention focused technology-mediated mHealth programs have not been customized and tested for OEF/OIF Veterans.

Stay Strong is one such program, funded by HSR&D and tested in a large-scale comparative randomized trial. Stay Strong is an mHealth intervention that was centrally administered with a smartphone app, Fitbit physical activity tracking device, and in-home Bluetooth weight scale.

The goals of the Stay Strong trial were to:

1) compare the impact of Stay Strong alone versus Stay Strong plus telephone and automated coaching components on physical activity among OEF/OIF Veterans.

2) evaluate the impact of these mHealth interventions on the secondary outcomes of weight loss, depression, and pain among OEF/OIF Veterans.

3) test for moderation of the intervention effect by gender with respect to the primary and secondary outcomes.

OEF/OIF Veterans were randomly selected and randomized into Stay Strong alone or Stay Strong plus coaching which included personalized exercise goals, tailored push notifications, and three phone-based health coaching calls in the first 6-8 weeks. Both programs ran for one year.

Findings:

  • OEF/OIF Veterans were clearly enthusiastic about the programs; recruitment goals (n=357) were met more quickly than expected, even without face-to-face contact and relying on online consent.
  • Neither program positively impacted physical activity levels; in fact activity levels decreased by the end of each of the 12-month programs.
  • Approximately two-thirds of participants stopped connecting their Fitbit device to report their physical activity level by the end of their 12month-program; thus many participants were lost to follow-up.
  • More research is required to guide design and customization of mHealth interventions such as Stay Strong for OEF/OIF Veterans.

Principal Investigator: Laura J. Damschroder, MPH, MS is a Research Investigator with the VA Center for Clinical Management Research and project principal investigator with the Personalizing Options through Veteran Engagement (PrOVE) QUERI at the VA Ann Arbor Healthcare System, Ann Arbor, MI.

Publications:

Buis LR, McCant FA, Gierisch JM, Bastian LA, Oddone EZ, Richardson CR, Kim HM, Evans R, Hooks G, Kadri R, White-Clark C, Damschroder LJ. Understanding the Effect of Adding Automated and Human Coaching to a Mobile Health Physical Activity App for Afghanistan and Iraq Veterans: Protocol for a Randomized Controlled Trial of the Stay Strong Intervention. JMIR research protocols. 2019 Jan 29; 8(1):e12526.


Development of a Weight Maintenance Intervention for Bariatric Surgery Patients

Weight Maintenance Intervention for Bariatric Surgery Patients

© iStock/huettenhoelscher

Impact: It could be offered by VA has long been a model healthcare system for implementation of centralized services via telemedicine. This intervention was designed to be integrated into existing systems by offering post-surgical counseling for bariatric surgery patients to geographically dispersed Veterans via a registered dietician in the Nutrition Service or within MOVE! infrastructure, either locally or nationally..(we don’t really care about how it might be used outside VA for the purposes of a feature)

VA performs approximately 500 bariatric operations per year across 17-21 sites. In a State-of-the-Art (SOTA) Conference on weight management co-led by Health Services Research and Development and by the National Center for Health Promotion and Disease Prevention (NCP), the bariatric surgery committee strongly agreed that future priorities for VA include increasing the number of sites that offer bariatric surgery and identifying strategies to help Veterans maintain weight loss resulting from surgery. This pilot intervention sought to help increase VA's return on investment as bariatric surgery volume increases over the next decade. Specific objectives were:

1) Refine existing telephone intervention scripts to address dietary, mobility, and behavioral issues specific to bariatric surgery patients.

2) Evaluate feasibility of conducting a multi-site trial, as indicated by recruitment and outcome assessment rates.

3) Evaluate intervention acceptability, as indicated by intervention adherence rates, pre-post changes in weight and process measures, and feedback from post-intervention qualitative interviews.

Once recruited, eligible Veterans (I think you need to say something about them being “post-bariatric surgery” or something as that isn’t obvious from the context, i.e. who is an “eligible” Veteran) from the Ann Arbor, West Roxbury, Palo Alto, and Long Beach VA medical centers received a baseline call, consisting of a 24-hour diet recall and several baseline measures administered verbally. Following the baseline telephone call, participants received phone calls weekly for the first month and biweekly for months 2-4. The first four calls focused on diet, physical activity, and supplement adherence content specific to post-bariatric surgery patients. Each subsequent call addressed maintenance skill building and anticipatory problem solving using the MAINTAIN protocol, which includes patient satisfaction with outcomes of behavior change, self-monitoring, recovery self efficacy/relapse planning, and social network support. Post-intervention semi-structured qualitative interviews were conducted via telephone within four weeks of the final outcome assessment.

Findings:

  • This is about the study methodology and won’t be of interest to a non-research reader.Pre-post changes in weight (73% with <3% weight regain) and physical activity supported the potential for the intervention to yield clinically significant results.
  • Intervention adherence (mean 7.8 calls of 9 received) and positive feedback from interviews supported treatment acceptability.

Principal Investigator: Corrine I. Voils, PhD, is a Research Career Scientist at the William S. Middleton Memorial Veterans Hospital, Madison, WI. She is also a Professor of Surgery at the University of Wisconsin-Madison, where she is Director of the Wisconsin Surgical Outcomes Research program.

Publications:

Voils CI, Adler R, Strawbridge E, Grubber J, Allen KD, Olsen MK, McVay MA, Raghavan S, Raffa SD, Funk LM. Early-phase study of a telephone-based intervention to reduce weight regain among bariatric surgery patients. Health psychology: official journal of the Division of Health Psychology, American Psychological Association. 2020 Jan 30.


Weight Loss Treatment and CBT for Veterans with Binge Eating

IWeight Loss Treatment and CBT for Veterans with Binge Eating

© iStock/South_agency

Impact: This study will provide important information about the effectiveness and durability of treatment approaches for overweight/obese Veterans with binge eating, and will inform future grants regarding the implementation of the treatment for binge eating across VA medical centers.

Obesity is a leading cause of preventable death in the US.  Veterans are disproportionately affected by obesity and have poor response to weight loss treatment. Of additional concern to VA is that binge eating, a problem strongly associated with psychiatric and medical illness, is highly prevalent among Veterans. Over three-quarters of overweight or obese Veterans who seek weight loss treatment engage in binge eating behavior resulting in suboptimal weight loss outcomes. Binge Eating Disorder (BED), a psychiatric condition in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), is additionally associated with increased risk of suicide attempts. In the Veterans Health Administration, Veterans with BED incur substantially higher healthcare costs and utilization. To date there are no treatments that have been established in VA to address binge eating. This study aims to leverage VA's national weight management program, MOVE!, by combining it with cognitive-behavioral therapy (CBT), the best-established treatment for binge eating.

Men and women with subclinical and clinical Binge Eating Disorder are being enrolled into a randomized control trial (RCT) comparing the effectiveness of treatment-as-usual (MOVE!) vs treatment-as-usual plus brief cognitive behavioiral therapy (MOVE!+BriefCBT). Major assessments occur at pre-treatment (baseline), post-treatment (3-months) and 6- and 12-months following treatments. The primary outcome will be improving binge eating and mental health, and exploratory outcomes will be improving weight loss treatment engagement and weight outcomes, including weight loss and biomarkers of disease.

Principal Investigator: Robin Meryl Masheb, PhD is a Senior Research Scientist in Psychiatry and Director of the Veterans Initiative for Eating and Weight (VIEW) at VA Connecticut Healthcare System West Haven Campus, West Haven, CT.

Publications:

Masheb RM, Chan SH, Raffa SD, Ackermann R, Damschroder LJ, Estabrooks PA, Evans-Hudnall G, Evans NC, Histon T, Littman AJ, Moin T, Nelson KM, Pagoto S, Pronk NP, Tate DF, Goldstein MG. State of the art conference on weight management in VA: Policy and research recommendations for advancing behavioral interventions. Journal of general internal medicine. 2017 Apr 1; 32(Suppl 1):74-78.

References

  1. VA Working to Improve Weight Management among Veterans. [Internet]. Washington (DC): US Department of Veterans Affairs; 2017. [cited 2020 May 1]. Available from: /news/feature/weightmgt.cfm#ref
  2. Quality of Care: Obesity. [Internet]. Washington (DC): US Department of Veterans Affairs; 2016. [cited 2020 May 1]. Available from: https://www.va.gov/QUALITYOFCARE/improving/Obesity.asp
  3. Obesity Is Not a Service-Connected Disability: VA. [Internet]. Weston (MA): Monster Worldwide Inc.; 2019. [cited 2020 May 1]. Available from:https://www.military.com/militaryadvantage/veteran-benefits/2019/04/05/obesity-not-service-connected-disability-va.html
  4. Office of Research & Development. [Internet]. Washington (DC): US Department of Veterans Affairs; 2020. [cited 2020 May 1]. Available from: https://www.research.va.gov/topics/obesity.cfm

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