Spotlight on Obesity, Weight Management, and Eating Disorders

January 2023

Introduction

Failing to maintain a healthy weight can affect short- and long-term health, raising the risk of a variety of health troubles, including type 2 diabetes, heart disease, joint pain, cancer, and dementia. While virtually everyone struggles at times to do what’s best for their weight and their health, Veterans can find it even tougher to manage as they navigate emotional and mental health challenges.

With more than 7 in 10 Veterans who receive VA care having overweight or obesity ¹, HSR&D investigators continue to study a range of factors related to weight, eating habits, and physical activity, such as how best to help Veterans eat and exercise properly as they grapple with PTSD, and how best to screen Veterans to stave off osteoarthritis, type 2 diabetes, or other health problems that can result from poor diet and lifestyle choices.

VA also offers programs for Veterans that can help with weight management, such as HSR&D’s Quality Enhancement Research Initiative (QUERI) Virtual Diabetes Prevention Program, an evidence-based lifestyle intervention for women Veterans that emphasizes moderate weight loss, diet, and physical activity and has been shown to prevent or delay progression to type 2 diabetes, helping Veterans to become more fit and enjoy a longer, better quality of life.

Following are some recent HSR&D studies on obesity, weight management, and eating disorders.

• Body Mass Index Risk Zones and Variations in Obesity Detection in Veterans with Spinal Cord Injury
• Patient-Centered Strategies to Engage Veterans in Behavioral Health Services
• Eating Disorders in Veterans: Risk, Resilience, and Service Use
• Move!+UP: Testing a Tailored Weight Management Program for Veterans with PTSD

Body Mass Index Risk Zones and Variations in Obesity Detection in Veterans with Spinal Cord Injury

The prevalence of obesity, a chronic disease associated with significant morbidity and mortality, is high among US Veterans, with more than two-thirds having overweight or obesity. Healthcare providers use body mass index (BMI) as a tool to estimate body fat and help assess patients’ risk for certain health conditions. As BMI is an accepted standard of care, VA and the DoD mandate annual universal BMI screening of Veterans for overweight and obesity.

About this study

Obesity in individuals with spinal cord injury (SCI) is common due to changes in body composition, changes in energy balance, and a significant decrease in mobility. However, due to these changes, it is likely that BMI underestimates obesity and obesity-related risk in patients with SCI compared to able-bodied individuals. Because of physical and logistical barriers to conducting height and weight assessments in Veterans with SCI, researchers have suspected that BMI is not consistently measured in this population.

To better understand the burden of obesity in Veterans with SCI and to identify individuals at risk for obesity-related morbidity, researchers sought to describe system-wide variation in BMI assessment. In addition, researchers assessed the longitudinal associations between BMI and obesity-related risk in Veterans with SCI, to determine if SCI-specific adjusted BMI risk zones are needed to properly recognize obesity and risk for comorbidity in this population.

Researchers aimed to:

• Characterize guideline-concordant BMI assessment in Veterans with SCI in FY16–FY18.
• Understand drivers of facility-level variation in BMI assessment in Veterans with SCI.
• Evaluate and calibrate SCI-specific, adjusted BMI-based morbidity risk zones in Veterans with SCI.

Findings are not yet available.

Implications

This research may inform practice and system organization for improved care and decreased variation in BMI assessment. It may also be used to design implementation and improvement strategies to facilitate guideline-concordant practices for Veterans with SCI throughout VA, especially in locations with currently low performance, enabling providers to identify SCI patients who are at risk for obesity and obesity-related disease who may otherwise go undetected. Dissemination of this study’s results throughout VA will improve understanding of the risk of obesity and obesity-comorbidity in this vulnerable population.

Principal Investigator

Dan Eisenberg, MD, MS, is part of the Center for Innovation to Implementation at the VA Palo Alto Healthcare System.

Publications

Recent publications of Dr. Eisenberg’s work with his colleagues include:

Eisenberg D, LaVela S, Frayne S, et al. Rates, variability, and predictors of screening for obesity: Are individuals with spinal cord injury being overlooked? Obesity Facts. March 9, 2022; 15(3):451–457.

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Patient-Centered Strategies to Engage Veterans in Behavioral Health Services

Nearly 80% of the Veterans who receive VA care have overweight or obesity⁵, which means many are at risk for costly and debilitating chronic conditions. Although VA offers weight management programs to 94% of Veterans, only about 10% of Veterans use them. Given clinicians’ limited time, there is a need for a motivational, self-help tool that can increase Veterans' engagement with weight management.

About this study

Motivational interviewing can improve patients’ engagement with weight management, but clinicians have limited time. To create a self-help tool, researchers used administrative database analyses and interviews with clinicians, national leaders, and Veterans to:

• Identify patient and organizational predictors of weight management engagement.
• Develop “Enhancing Motivation for Better Engagement and Reach” (EMBER), a motivational, self-help tool to increase weight management engagement.
• Pilot test EMBER to prepare for a larger trial of its effectiveness.

Findings

• Among Veterans using VA primary care, 38% had a body mass index (BMI) in the overweight range, and 41% had a BMI in the obesity range.
• Rates of obesity were especially high among some subpopulations, including Black women and people with psychiatric diagnoses.
• Interviews with VA staff identified a variety of weight management programs available to Veterans, including MOVE!, nutrition clinics, and recreation therapy clinics.
• Interviews with Veterans identified varied beliefs about weight and weight management, including a focus on appearance among younger Veterans and health among older Veterans. Women Veterans tended to have more negative views of obesity and its consequences than men.

Implications

This research helped identify how Veterans understand weight and weight management and led to the development of EMBER, which is currently being tested in an effectiveness implementation trial (HSR&D IIR 19-422). If EMBER is effective, findings may lead to increased engagement in weight management programs that will improve the physical and emotional health of Veterans. Results may also facilitate understanding of and improvements in engagement and outcomes related to other behavioral health treatments.

Principal Investigator

Jessica Yelena Breland, PhD, MS, is an investigator with HSR&D’s Center for Innovation to Implementation at the VA Palo Alto Healthcare System in Palo Alto, CA.

Publications

Recent publications of Dr. Breland’s work with her colleagues include:

Breland J, Dawson D, Puran D, et al. Common sense models of obesity: A qualitative investigation of illness representations. International Journal of Behavioral Medicine. April 20, 2022;1–9.

Gray K, Hoerster K, Breland J, et al. National Veterans Health Administration MOVE! weight management program participation during the COVID-19 pandemic. Preventing Chronic Disease. March 10, 2022;19:210303.

Lohnberg J, Salcido L, Breland J, et al. Rapid conversion to virtual obesity care in COVID-19: Impact on patient care, interdisciplinary collaboration, and training. Obesity Science & Practice. February 1, 2022;8(1):131–136.

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Eating Disorders in Veterans: Risk, Resilience, and Service Use

Eating disorders (EDs) can severely affect physical and emotional health and significantly raise the risk of death. ² Unique features of military life, such as trauma and strict weight and fitness requirements, might increase the risk of developing an ED, and studies reveal high prevalence estimates of EDs among military and Veteran men and women.^{3 4}

Individuals with EDs are likely to be frequent users of medical care, at least partly because of the physical complications of EDs. Nonetheless, EDs often go undetected in general medical settings unless providers screen for them. Because VA does not routinely screen for EDs, there is an urgent need to expand VA's capacity nationally to provide comprehensive care for Veterans with EDs.

About this study

In 2020, researchers mailed a survey to a nationally representative sample of male and female Veterans (N = 1,187) to address 4 major gaps that create barriers to ED screening and treatment in VA healthcare. Researchers aimed to:

• Examine the prevalence of male and female Veterans who report full and subthreshold EDs, and examine the prevalence of EDs among vulnerable subgroups of Veterans.
• Identify service use and needs among male and female Veterans with full and subthreshold EDs.
• Estimate Veterans’ risk and protective factors for EDs.
• Validate an existing screening measure of EDs in a Veteran sample and assess Veterans’ screening preferences.

In 2021, researchers sent a second survey to Veterans who consented to be recontacted (n = 689). The main aim of this data collection was to address how ED symptoms changed during the COVID-19 pandemic.

Findings

• EDs were prevalent among Veterans across subgroups of age, ethnicity, race, and body size. Nineteen percent of women and 9% of men met probable criteria for any full or subthreshold ED.
• Veterans with EDs were 5 times more likely to report using any mental healthcare compared to Veterans without EDs. Medical care use, however, did not differ significantly for Veterans with EDs compared to those without EDs.
• Trauma exposure was associated with EDs and ED symptoms in Veteran men and women.
• Screening measures likely perform adequately in Veteran men and women, although it will be important to further investigate specific cutoff scores in this population. Male and female Veterans responded favorably to ED screening.
• Veterans with early pandemic PTSD, depression, anxiety, and stress symptoms were particularly vulnerable to EDs that persisted from 2020 to 2021.

Implications

Study findings underscore the need for early intervention for EDs, and will inform ongoing provider trainings. Researchers will disseminate findings via cyberseminars and newsletters, and will develop clinician and executive briefs to disseminate findings to clinicians and policy makers.

Principal Investigator

Karen Mitchell, PhD, is a clinical research psychologist with the National Center for PTSD’s Women’s Health Sciences Division at VA Boston Healthcare System.

Publications

Recent publications of Dr. Mitchell’s work with her colleagues include:

Hardin S, Vogt D, Mitchell K, et al. Male and female Veterans' preferences for eating disorders screening. Journal of General Internal Medicine. September 1, 2022;37(Suppl 3):819–822.

Mitchell K, Sienkiewicz M, Smith B, et al. Associations between probable eating disorders and healthcare use among post-9/11 Veteran men and women. Journal of Psychosomatic Research. June 1, 2022;157:110811.

Mitchell K, Masheb R, Smith B, et al. Eating disorder measures in a sample of military veterans: A focus on gender, age, and race/ethnicity. Psychological Assessment. July 2021;33(12):1226–1238.

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Move!+UP: Testing a Tailored Weight Management Program for Veterans with PTSD

Post-traumatic stress disorder (PTSD) is prevalent among Veterans and is considered a possible risk factor for obesity and related conditions. Veterans with PTSD lose less weight than other Veterans in VA’s MOVE! weight management program due to PTSD symptoms that interfere with activity and a healthy diet. To address these barriers, researchers developed MOVE!+UP, which adapts VA’s MOVE! program to deliver weight management care while targeting PTSD-related weight loss barriers.

Veterans who received MOVE!+UP in an uncontrolled pilot trial reported high satisfaction and reduced PTSD symptoms and weight. Participants also reported improvement on treatment targets such as eating behaviors, activity, and insomnia. Although MOVE!+UP has the potential to reduce weight and PTSD symptoms, its effectiveness must be tested in a randomized trial.

About this study

This ongoing (October 2020–September 2024) HSR&D study will test the effects of MOVE!+UP on weight and PTSD symptoms. In addition, cost analyses and identification of implementation barriers and facilitators will place effectiveness findings in context and facilitate rapid translation to the field if MOVE!+UP is effective. This study will also provide insights about ways that general MOVE! and PTSD care can be enhanced to improve reach and effectiveness. Researchers aim to randomize 164 Veterans with PTSD and overweight or obesity enrolled in PTSD care to MOVE! (control) or MOVE!+UP (intervention). Researchers will:

• Test whether intervention participants have greater 6- and 12-month weight loss and PTSD symptom reduction relative to the control group.
• Assess whether, compared to the control group, intervention participants have greater improvements of 6-month treatment targets: physical activity, eating behavior, insomnia, depression, and social support.
• Estimate intervention and control condition costs and use, and identify MOVE!+UP implementation barriers and facilitators.

Findings are not yet available.

Expected implications

MOVE!+UP is the first weight loss program designed to address obesity in Veterans with PTSD. This study will provide data needed to determine MOVE!+UP’s effectiveness and prepare a MOVE!+UP implementation package for broader VA implementation if MOVE!+UP is effective. Implementation activities would be coordinated with existing local, VISN, and national operational partners.

Principal Investigator

Katherine D. Hoerster, PhD, MPH, is with the Seattle-Denver Center of Innovation at the VA Puget Sound Health Care System in Seattle, WA.

Publications

Recent publications of Dr. Hoerster’s work with her colleagues include:

Robustelli B, Campbell S, Hoerster K, et al. Table for two: Perceptions of social support from participants in a weight management intervention for veterans with PTSD and overweight or obesity. Psychological Services. November 1, 2022;19(4):719–729.

Hoerster K, Tanksley L, Sulayman N, et al. Testing a tailored weight management program for Veterans with PTSD: The MOVE!+UP randomized controlled trial. Contemporary Clinical Trials. August 1, 2021;107:106487.

Hoerster K, Tanksley L, Simpson T, et al. Development of a tailored behavioral weight loss program for Veterans with PTSD (MOVE!+UP): A mixed-methods uncontrolled iterative pilot study. American Journal of Health Promotion. July 2020;34(6):587–598.

Development and testing of MOVE!+UP, along with comments from participating Veterans, were featured in the September 2020 issue of HSR&D’s Veterans’ Perspectives.

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