Health Services Research & Development

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VA Working to Improve Weight Management among Veterans

January 2017


Resources

The American Diabetes Association provides an online Diabetes Risk Test.

Diabetes. National Institute of Diabetes and Digestive and Kidney Diseases.

Healthcare systems are challenged by steady increases in the numbers of patients who are overweight and obese. According to the National Center for Health Statistics for the years 2013-2014, 38% of American adults age 20 years and older are obese, and 71% of adults over the age of 20 are overweight. Moreover, 21% of adolescents ages 12-19 are obese, 17% of children ages 6-11 are obese, and 9% of children ages 2-5 are obese.1 In 2014, VA estimated that 78% of Veterans were overweight or obese, and in 2013, more than 165,000 Veterans who received VA healthcare were morbidly obese (BMI <40), which can interfere with basic physical functions and significantly increase the risk of obesity-related conditions (e.g., diabetes, hypertension, cardiovascular disease).2

Working toward implementing a more integrated system-wide approach to improving weight management for Veterans, as well as enhancing the care they receive, HSR&D held a state-of-the-art conference (SOTA) titled "Weight Management in the Veterans Health Administration (VHA)" in 2016. Topics that were discussed included issues important to improving weight management among VA patients, such as behavioral interventions, pharmacotherapies, and bariatric surgery. Papers produced as a result of this SOTA will appear in an upcoming special supplement of the Journal of General Internal Medicine.

HSR&D Research on Weight Management

Following are descriptions and findings from several specific research projects conducted by HSR&D investigators issues critical to improving weight management among Veterans.

Choosing a Diet versus Having an Assigned Diet Does Not Lead to Greater Weight Loss

A variety of dietary approaches have proven effective for weight management, but regardless of the approach, a higher adherence to dietary recommendations has been the best predictor of weight loss. Therefore, new strategies that maximize dietary adherence are needed to help patients experience maximum health benefits. This randomized trial, funded by HSR&D, evaluated whether Veterans allowed the opportunity to choose between two diets would have greater weight loss than Veterans randomly assigned a diet. Study participants with a body mass index (BMI) of >30 (obese) and a regular VA provider were recruited from VA clinics in Durham, NC between May 2011 and June 2012. Veterans were then randomized to the Choice group (n=105) or the Comparator group (n=102). Choice group participants received information about their food preferences and two diet options (low-carbohydrate diet [LCD] or low-fat, reduced-calorie diet [LFD]), and were allowed to switch diets at 12 weeks. Participants in the Comparator group were randomly assigned to one diet for 48 weeks. The primary outcome – body weight – was measured at each of the 19 visits over 48 weeks. Findings show:

  • Contrary to popular opinion, the option of choosing a diet to follow, as opposed to being assigned a diet, did not improve weight loss among obese Veterans. At 48 weeks, the estimated mean weight loss was 12.5 pounds for Veterans in the Choice group and 14.8 pounds for Veterans in the Comparator group.
  • Secondary outcomes of dietary adherence, physical activity, and weight-related quality of life were similar between groups.

Implications: Given that diverse diets have proven effective for weight loss, future research might examine matching patients to their optimal diet based on other characteristics (e.g., metabolic profile, genetics) instead of their preferences.

Yancy W, Mayer S, Coffman C, et al. Effect of allowing choice of diet on weight loss: A randomized trial. Annals of Internal Medicine. June 16, 2015;162(12):805-14.

Mental Health Conditions Common among Patients Seeking Bariatric Surgery

Bariatric surgery is an accepted method of promoting weight loss and improving obesity-related physical comorbidities in severely obese individuals. Funded through HSR&D's Evidence-based Synthesis Program, this systematic review sought to: 1) estimate the prevalence of mental health conditions among bariatric surgery candidates and recipients; 2) evaluate the association between preoperative mental health conditions and weight loss after surgery; and 3) evaluate the association between surgery and the clinical course of mental health conditions. Investigators searched the literature between January 1988 and November 2015, identifying 68 publications that met inclusion criteria. Findings show:

  • Mental health conditions are common among patients seeking and undergoing bariatric surgery, particularly depression and binge-eating disorder (BED).
  • There was inconsistent evidence regarding the association between preoperative mental health conditions and postoperative weight loss. Five studies on preoperative depression and five on preoperative binge eating disorder yielded mixed results.

Implications: Prevalence estimates for mood disorders (22%), depression (19%), and BED (17%) among individuals seeking or undergoing bariatric surgery were higher than published rates for the general U.S. population (10%, 8%, and 1-5%, respectively), suggesting that special attention should be paid to these conditions among bariatric patients.

Dawes A, Maggard-Gibbons M, Maher A, Booth M, Miake-Lye I, Beroes J, and Shekelle P. Mental health conditions among patients seeking and undergoing bariatric surgery: A meta-analysis. JAMA. January 12, 2016;315(2):150-63.

Study Examines Health Benefits of Bariatric Surgery among Obese Veterans

This HSR&D-funded study examined long-term survival and weight change in a large, multi-site cohort of obese Veterans who underwent bariatric surgery compared to matched controls. Using data from VA's Surgical Quality Improvement Program (VASQIP), investigators identified 2,500 Veterans (74% male) who underwent bariatric surgery in VA bariatric centers from 1/00 through 9/11, and matched them to 7,462 control patients. The main outcome in the survival analysis was all-cause mortality through December 2013. Investigators also conducted analyses of effect modification by sex, diabetes diagnosis, period of surgery (2000-2005 vs. 2006-2011), or super-obesity (body mass index >50).

  • Obese Veterans who underwent bariatric surgery had lower all-cause mortality starting at 5 years and up to 14 years following the procedure than matched controls.

  • After a mean follow up of 6.9 years in the surgical group and 6.6 years in the matched control group, study analyses estimated 1-year, 5-year and 10-year mortality rates that were 2%, 6% and 14% for Veterans who underwent bariatric surgery, and 2%, 10% and 24% for Veterans who did not undergo bariatric surgery.1

While research indicates that bariatric surgery is the most effective intervention for inducing weight loss among obese patients, much less is known about sustained weight loss after surgery. Another analysis from this HSR&D study compared 10-year weight change between 1,787 Veterans who underwent Roux-en-Y gastric bypass (RYGB) and 5,305 Veterans who did not undergo surgery. It also compared 4-year weight change between RYGB patients and 379 Veterans who underwent sleeve gastrectomy (SG) and 246 Veterans who underwent adjustable gastric banding (AGB). The main outcome was weight change up to 10 years after surgery (through December 2014). Findings show:

  • Among obese Veterans who received VA care, patients who underwent RYGB lost much more weight than matched non-surgical patients – and were able to sustain most of this weight loss in the long term. RYGB patients had lost 21% more of their baseline weight at 10 years than matched non-surgical patients.
  • Among surgical patients, RYGB patients experienced the greatest weight loss (28%) after four years. SG patients experienced significantly less weight loss than RYGB (18%), while AGB patients lost the least weight (11%).2

Implications: Thesestudy results provide further evidence for the health benefits (improved survival, sustained weight loss) of bariatric surgery that has been demonstrated in younger, predominantly female, non-VA populations.

1. Arterburn D, Olsen M, Smith V, Livingston E, Van Scoyoc L, Yancy W, Eid G, Weidenbacher H, and Maciejewski M. Association between bariatric surgery and long-term survival. JAMA. January 6, 2015;313(1):62-70.

2. Maciejewski M, Arteburn D, Van Scoyoc L, et al. Bariatric surgery and long-term durability of weight loss. JAMA Surgery. November 2016; 151(11):1046-1055.

Shared Medical Appointments for Diabetes with Weight Management

Shared medical appointments (SMAs) involve groups of patients who share a common chronic condition and meet over time to receive education, self-management enhancement, and medication management to improve clinical outcomes. A systematic review by VA found that SMAs modestly improve glycemia in patients with diabetes. A combination of an intensive weight management program with the diabetes management offered in SMAs has the potential to further improve diabetes outcomes, reduce complications, decrease costs and increase health-related quality of life. Therefore this ongoing HSR&D study will examine whether an intensive, group-based weight management program followed by an SMA intervention is comparably effective to the SMA intervention alone for improving glycemic control, while using less anti-glycemic medication and resulting in fewer hypoglycemic events and lower healthcare costs.

This randomized controlled study will recruit 308 overweight VA outpatients with uncontrolled type 2 diabetes. The weight management arm of the study will focus on a low carbohydrate dietary pattern because of its potential to lower glycemia, leading to reduced anti-glycemic medication needs. After 16 weeks, meeting content will shift to the SMA intervention content, but weight management will continue to be addressed at the meetings. The primary outcome is glycemic control assessed by hemoglobin A1c, which is examined at baseline and again at 16, 32, and 48 weeks. Secondary outcomes include hypoglycemic events, changes in anti-glycemic medication regimen, weight and healthcare costs. Diabetes-specific health-related quality of life and medication adherence also is being evaluated.

Implications: This research is important because diabetes is more prevalent in Veterans than in the general population, and because weight management is more challenging and complex in patients with diabetes.


References:

1. Centers for Disease Control and Prevention (CDC). National Center for Health Statistics. Obesity and Overweight.

2. Arterburn D, Livingston E, Olsen M, et al. Predictors of initial weight loss after gastric bypass surgery in twelve Veterans Affairs Medical Centers . Obesity Research and Clinical Practice September 2013;7(5):e367-e376.