VA developed the MOVE! weight management program to address obesity but 50% of Veterans who enroll in MOVE! attend only one session and evaluations suggest modest weight loss and potential gender and racial/ethnic disparities in outcomes. MOVE! was implemented with flexibility in program design, with some standard elements and others determined locally. Little is known about how well these local variations meet the needs of the populations served. Growing evidence suggesting the importance of environmental attributes (e.g., healthy food availability, walkability, access to recreational places such as parks) in obesity-related behaviors points to a promising new direction for investigation: the interplay between weight management interventions and the environment in influencing people's ability to adopt and sustain healthy lifestyles.
The goal of this project was to understand environmental contributions to MOVE! engagement and outcomes and how best to assist Veterans in adopting lifestyle change through MOVE! by taking into account the residential environment. Specific aims were to determine the extent to which (1) Local MOVE! elements are aligned with Veterans' residential environment attributes; (2) Specific MOVE! elements promote engagement for Veterans living in environments with or without facilitating attributes; (3) Attributes of the residential environment and specific MOVE! elements interact to help MOVE! participants lose weight at 6 months and maintain weight loss at 18 months; and (4) African American, Hispanic, female, and rural Veterans are different from their Non-Hispanic White, male, and urban-dwelling counterparts in regard to the environment-MOVE! relationships and impacts on weight loss examined in Aims 2 and 3.
This was a retrospective observational study in which we linked VA healthcare, MOVE!, and non-VA data from public and proprietary sources. The study population was Veterans using VA health care in 2009-2013 (the most recent year for which MOVE! program data were available). We identified four samples for separate analysis, differentiated according to gender and metropolitan versus non-metropolitan location. For each we used a propensity modeling approach to derive a control group. Environmental variables of interest were measures of spatial access to supermarkets, convenience stores, fast-food restaurants, food-focused big-box stores, parks, commercial fitness facilities, and walkable areas. Spatial access was measured from each Veteran's home location. MOVE! program variables were obtained from annual reports submitted in 2009-2011 and 2013 by the MOVE! coordinator at each facility and included staffing measures (discipline-specific FTE, adjusted for facility population; primary care involvement, multiple-discipline involvement), physical activity components (on-site space, incorporated into sessions), use of telehealth modalities, and availability of group care focused on weight loss maintenance.
Aim 1 was a VA facility-level analysis that examined correlations between within-facility changes in MOVE! program elements and changes in their populations' food and physical activity environments. In Aims 2-4, we used OLS regression models incorporating inverse propensity score weights to assess relationships between environment-MOVE! program alignment and MOVE! program participation (Aim 2), defined as two or more MOVE! visits within 6 months, and outcomes (Aims 3-4) measured as BMI change at 6, 12, 18, and 24 months.
The metropolitan samples comprised 68,964 and 368,060 male and 28,888 and 10,263 female MOVE! participants and controls, respectively. On average, Veterans in metropolitan areas lived within one mile of 1.1 (SD 1.9) supermarkets, 4.2 (SD 4.9) convenience stores, 9.3 (SD 17.3) fast-food restaurants, 2.4 (SD 2.9) parks, and 3.5 (SD 7.1) commercial fitness facilities. The non-metropolitan samples comprised 11,869 and 62,891 male and 1,280 and 2,838 female MOVE! participants and controls, respectively. On average, Veterans in non-metropolitan areas lived within three miles of 1.2 (SD 1.6) supermarkets, 5.2 (SD 6.4) convenience stores, 7.9 (SD 10.5) fast-food restaurants, and 3.5 (SD 4.9) commercial fitness facilities.
MOVE! program elements (e.g., dietician staffing, on-site physical activity space) were weakly correlated with food and physical activity attributes of Veterans' residential environments (e.g., availability of supermarkets or convenience stores, park availability). We found no evidence that MOVE! programs vary elements such as staffing or availability of space for physical activity in response to changes in the environments in which their facilities' populations reside.
AIM 2: MOVE! participation outcome
We found that, among Veterans living 30 miles or more from the nearest VA medical center, provision of MOVE! through clinical video telehealth at the nearest community-based outpatient clinic (CBOC) resulted in greater likelihood of MOVE! participation. That effect declined, however, with greater distances between home and the CBOC. We found no evidence that other MOVE! program elements (e.g., dietician FTE, physical activity component) affected participation, in metropolitan or non-metropolitan areas.
AIMs 3 and 4: BMI change outcome
Among male Veterans living in metropolitan areas, we found that clinical staffing (FTE) devoted to MOVE! modified the effect of neighborhood walkability on program effectiveness; Veterans living in more walkable areas lost more weight in MOVE! when their facility's program had higher levels of clinical FTE. Among women Veterans living in metropolitan areas, we found that clinical staffing (FTE) devoted to MOVE! modified the effect of fitness facility access on program effectiveness; Veterans living nearest to a fitness facility lost more weight in MOVE! and even more when their facility's program had higher levels of clinical FTE. For both men and women, these effects were very small in magnitude.
Among men and women Veterans living in non-metropolitan areas, we found no evidence that Veterans' ability to lose weight in MOVE! was affected by alignment between MOVE! program elements and the food and physical activity attributes of their neighborhoods. In general, we found greater effects of the environment on MOVE! outcomes among men than women, regardless of program-environment alignment. Results did not differ by Veteran race.
The study results have implications for MOVE! program planning. The quality of food and physical activity resources available to Veterans in their neighborhoods varies widely. Previous work has demonstrated effects of the environment on MOVE! outcomes. MOVE! programs are managed locally, providing opportunities to better respond to Veterans' needs based on their environments and reduce variation in outcomes.
- Zenk SN, Tarlov E, Wing CM, Matthews SA, Tong H, Jones KK, Powell L. Long-Term Weight Loss Effects of a Behavioral Weight Management Program: Does the Community Food Environment Matter?. International journal of environmental research and public health. 2018 Jan 26; 15(2).
- Tarlov E, Zenk SN, Matthews SA, Powell LM, Jones KK, Slater S, Wing C. Neighborhood Resources to Support Healthy Diets and Physical Activity Among US Military Veterans. Preventing chronic disease. 2017 Nov 9; 14:E111.
- Zenk SN, Tarlov E, Wing C, Matthews SA, Jones K, Tong H, Powell LM. Geographic Accessibility Of Food Outlets Not Associated With Body Mass Index Change Among Veterans, 2009-14. Health affairs (Project Hope). 2017 Aug 1; 36(8):1433-1442.
- Zenk SN, Tarlov E, Powell LM, Wing C, Matthews SA, Slater S, Gordon HS, Berbaum M, Fitzgibbon ML. Weight and Veterans' Environments Study (WAVES) I and II: Rationale, Methods, and Cohort Characteristics. American Journal of Health Promotion : AJHP. 2018 Mar 1; 32(3):779-794.
- Jones KK, Zenk SN, Tarlov E, Powell LM, Matthews SA, Horoi I. A step-by-step approach to improve data quality when using commercial business lists to characterize retail food environments. BMC research notes. 2017 Jan 7; 10(1):35.