Obesity is a leading contributor to morbidity and mortality in the US. Obesity and overweight are highly prevalent among VA patients: As with the general population, over two-thirds of VA users are either overweight or obese. There is good evidence that moderately intensive weight reduction programs like the VHA MOVE! program have a modest but clinically significant impact on weight. Evaluations of MOVE! suggest it is effective, but most overweight and obese Veterans do not participate when it is suggested by their primary care provider (PCP). Veterans reported to us that the timing (workday hours) and location (Zablocki VAMC or ZVAMC) of MOVE! activities were barriers to participation. Previous research has found that most people regain much of their lost weight during the year after completing weight loss program activities. We attempted to address these issue by delivering a MOVE!-like program, which we called "MOVE OUT" in community settings that allowed friends and family to accompany participating Veterans. This would allow long term behavior change by forming a community of peers, friends and family who would support ongoing efforts to improve physical activity levels and dietary choices. An unique partnership with Veterans organizations made this program feasible. We evaluated it with an innovative study design that relied on clinical data to assess the impact of the program on all eligible Veterans.
Our primary goal was to demonstrate that the MOVE OUT program could increase the average weight loss among ZVAMC users and thereby reduce blood pressure , by increasing the proportion participating in a moderately intensive weight management program. We also sought to understand factors that influenced whether individual veterans and community sites were more successful in changing behavior and delivering the intervention with high fidelity, respectively.
We tested the following specific hypotheses:
1)Was weight loss at 2 years greater among veterans receiving primary care at ZVAMC who were invited to participate in MOVE OUT than in those who were not invited.
2)Did Veterans receiving primary care at ZVAMC who were invited to participate in MOVE OUT have more improvement in diet and exercise than those than in those who were not invited.
We used an innovative cluster randomized trial design. Eligibility criteria included having a visit to their ZVAMC PCP in last 3 months, but not during the last month; A diagnosis of hypertension or diabetes mellitus and most recent BMI > 25 kg/m2 OR most recent BMI > 30 kg/m2 ; No scheduled appointment for a MOVE program clinic; and Age < 75 years. We allocated 3168 eligible Veterans in groups of 13-25 to be invited or not invited to come to MOVE OUT sites. Although eligibility for standard MOVE! programming was not changed by study participation, we refer to these groups as the MOVE OUT or MOVE! groups, respectively. We used clinically gathered weight, blood pressure and laboratory data to determine changes in weight, systolic blood pressure (SBP), low density lipoprotein and high density lipoprotein cholesterol (LDL-C and HDL-C, respectively) and hemoglobin A1c (HbA1c).
We recruited 251 of these Veterans (125 assigned to MOVE OUT) to participate in the process substudy. These Veterans provided written informed consent, then completed questionnaires at baseline, 12 and 24 month study visits to assess changes in diet, exercise and attitude, and use of VA and non-VA programs related to diet and exercise. We also directly measured BP and weight at these visits.
We used direct observation of MOVE OUT sites, telephone and in person surveys, semi-structured interviews, and focus groups to identify patient and program characteristics that were associated with patient participation, quality of implementation by the site and peer leaders success and persistence.
Twenty community sites participated in the MOVE OUT program. Two more sites volunteered but the affiliated peer leaders never went through training; peer leaders at two other site were trained but did not conduct any program sessions. At least 12 community sites were in operation throughout the intervention phase; ten elected to continue operations after the end of the intervention.
We randomly assigned 3169 (mean age 59.5 years; 3.8% female; mean weight 229.6 pounds; mean SBP 133.0 mmHg; mean LDL-C 97.2 mg/dl; mean HDL-C 42.8 mg/dl; mean HbA1c 6.69%) veterans in 5 waves at 2 month intervals to receive (n=1571) or not receive (n=1598) invitations to MOVE OUT. Mean weight at baseline was 229.6 pounds. By 2 years of follow up, 61 randomized veterans had died and 252 did not have follow up visits to Zablocki VA. An additional 391 did not have follow up weight available, leaving 2465 (n=1231 control; n=1234) for analysis. The two groups had similar demographics, weight, SBP, LDL-C, HDL-C and HbA1c at baseline.
After two years of follow up, mean weight loss was 1.55 pounds for the 2465 participants who had a weight at the two year mark. This was similar in the MOVE OUT and MOVE! groups (1.77 vs 1.33 pounds, p = 0.49). The modest changes in systolic BP (+ 0.90 mmHg), HDL-C (+2.1 mg/dl), LDL-C (-4.9 mg/dl), and HbA1c (-0.04%) were also similar in the two groups. These results were not changed when we used the last observation carried forward method for our dependent variables (e.g., the change in weight was 1.19 and 1.78 pounds for the MOVE and MOVE OUT groups, respectively, p = 0.28). Results were again similar when we adjusted for possible confounders.
Our site visits found that very few veterans took advantage of MOVE OUT sessions or obtained the reduced price memberships in local exercise facilities.
Process sub-study data showed that individual participants did not change diet or exercise habits, nor did they change their level of interest in losing weight.
We demonstrated that it is possible to deliver MOVE! - like services in community locations in partnership with Veterans Service Organizations, supporting VHA's efforts to leverage community partnerships. However, this approach did not increase veteran participation in the program. Although weight management is suited to a disseminated delivery model (e.g., Weight Watchers and TOPS), our study suggests that addressing convenience is insufficient by itself to significantly increase participation in MOVE!, though it may be part of a multi-pronged effort.
- Batch BC, Goldstein K, Yancy WS, Sanders LL, Danus S, Grambow SC, Bosworth HB. Outcome by Gender in the Veterans Health Administration Motivating Overweight/Obese Veterans Everywhere Weight Management Program. Journal of women's health (2002). 2018 Jan 1; 27(1):32-39.