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Improving Weight Management at VA: Enhancing the MOVE!23 for Primary Care (CDA 10-206)
Melanie R. Jay, MD MS
Manhattan Campus of the VA NY Harbor Healthcare System, New York, NY
New York, NY
Funding Period: October 2012 - June 2018
Veterans shoulder a disproportionate burden of obesity and its co-morbidities, and modest weight loss in obese patients through diet and exercise improves health outcomes. The VA currently offers the MOVE! program to treat obesity, but only 9% of eligible patients utilize this consultation service. At the same time, Veterans on average see their Primary Care Providers (PCPs) 3.6 times per year, supporting the importance of developing primary care-based interventions. Interactive behavior change technologies utilizing expert system software programs can facilitate behavior change in primary care. The MOVE!23 software is an expert system program for patients referred to MOVE!, but is not currently used in primary care by PACT. For my CDP, I will use qualitative methods to better understand the optimal use of goal-setting for weight management in an urban VA patient population and use state-of-the-art software evaluation methods to identify ways to enhance the MOVE!23 software to better facilitate goal-setting. I will then use this information to develop a brief intervention to treat obesity in Veterans that utilizes the enhanced MOVE!23 software and PACT to promote goal-setting, behavior change, and weight loss.
The three main objectives of my CDA are to: 1) using qualitative methods, enhance the MOVE!23 software and determine optimal goal setting processes to develop a brief, computer-assisted intervention to treat obesity; 2) determine the feasibility and acceptability of this brief intervention for urban, obese, VA patients within PACT; 3) explore the impact of this brief intervention on intermediate, behavioral, and weight loss outcomes at 3, 6, and 12 months post-intervention.
Based on focus groups (n=56), key informant interviews (n=25), and usability testing of the MOVE!23 questionnaire, we developed the MOVE Towards Your Goals Intervention (MTG).
Pilot test of intervention: Veterans with overweight/obesity and upcoming primary care visits are recruited to participate in MTG through mailings and phone calls. The first 11 Veterans were recruited into a non-randomized pilot test and received the MTG (MOVE Towards Your Goals Intervention) intervention. The pilot test (n=11) informed the development of a pilot randomized controlled trial (RCT).
Pilot RCT: Veterans with a Body Mass Index 30 or 25-29.99 kg/m2 with existing comorbidities were recruited by phone in two phases approximately six months apart, and randomized to MTG or "Enhanced Usual Care (EUC)," a control group. Participants in MTG meet with a health coach to set lifestyle and weight-loss goals and use a tablet-delivered goal-setting tool to facilitate in-person and phone coaching. In Phase 1, patients received baseline counseling immediately prior to their PC visit in order to activate discussion with their doctor. In Phase 2, we changed the protocol so that patient met with the health coach independent of the PC visit in order to facilitate scheduling and recruitment. In both phases, patients in the control met briefly with a coach to receive patient education materials. At baseline, 3, 6, and 12 months, participants were weighed and completed surveys. We assessed differences in outcomes between phase one and two.
Non-Randomized Pilot Test of MTG Intervention: We recruited 11 Veterans to participate in the non-randomized pilot study (91% male, 46% Black, 27% White, 27% Hispanic, mean age= 55.36 years (SD=15.10), mean BMI=30.1 kg/m2 (SD=4.47)). Immediately after the baseline health coaching session, 11/11 participants had set lifestyle goals, 8/11 increased or maintained motivation to lose weight, and 11/11 increased or maintained confidence in ability to lose weight. Two participants dropped out of the study and 1 was lost to follow up. At 3 months, a per-protocol analysis found that 8/8 participants engaged in phone coaching (range 2-6 calls, mean of 4 calls). Furthermore, 7/8 participants expressed interest in involvement in intensive weight loss programs at the VA and of those, 1 participant enrolled in and showed continued involvement. Four (50%) participants lost more than 1 kg, 3 of whom (37.5%) had 5% weight loss. Two (25%) stayed within 1 kg of their original weight, and 2 (25%) gained more than 1 kg. The mean weight change was -1.33 kg (SD 5.5).
Pilot RCT of MTG Intervention: 31 Veterans enrolled in phase 1 (mean age 53.48, 63% male, mean BMI 31.71, 54.84% African American, 22.58% White) and 14 enrolled in phase 2 (mean age 56.57, 79% male, mean BMI 30.27, 50% African American, 23.08% Hispanic). Overall, participants in the MTG intervention arm (phase 1 and phase 2 combined, N=21) tended to lose more weight at three-months, six-months and 12-months as compared to EUC (-0.80 ± 1.95 vs. 0.07 ± 2.40; p= 0.07, -1.52±3.05 vs. 0.23 ± 3.64; p=0.08 and-1.02 ± 4.16 vs. 0.74 ± 4.90; p=0.40 for three-, six-, and twelve- months, respectively). There were no statistically significant differences in dietary or physical activity changes between the two groups. Intervention participants also reported higher dietary self-efficacy (4.89 ± 9.02) than control (0.30 ± 13.69) p=0.22.
The MTG intervention was shown to be feasible and acceptable to patients within the patient-centered medical home model of care at the Veterans Affairs and led to small amounts of weight loss at 12 months A major limitation of this study was that we were underpowered to see statistically significant change in weight loss and other clinically-important outcomes. Future research is needed to test the efficacy and cost-effectiveness.
This study provided pilot data for two funded randomized controlled trials to test the efficacy of interventions based on the MTG intervention. More specifically, these results led to improvements in the training of both health coaches and primary care physicians at the Veterans Health Administration.
This study informed the development of the following two studies:
1. National Institutes of Health R01: DK111928-01 09/2016-08/2021 $2,740, 895: Testing the Efficacy of a Technology-Assisted Weight Management Intervention within Patient-Centered Medical Homes: The GEM (Goals for Eating and Moving) Study (R01)
Description: This study is testing the intervention (formerly called MTG) in a cluster randomized trial conducted at the Manhattan VA and at Montefiore Medical Center using non-clinician student health coaches
2. VA Health Services Research and Development IIR: HX002119-01A1 06/2017-5/2020 $1,100,000 :Testing the efficacy of a technology-assisted intervention to improve weight management of obese patients within Patient Aligned Care Teams at the VA( IIR )
Description: This study will test the intervention at the Brooklyn VA in a cluster randomized controlled trial using Veteran peer- health coaches)
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DRA: Diabetes and Other Endocrine Disorders
DRE: Treatment - Observational, Technology Development and Assessment
MeSH Terms: none