By Stephen Spotswood
ATLANTA – Can lifestyle changes be achieved in a large-scale healthcare setting, with patients maintaining improvement over several years?
An Emory University study of VA’s Managing Obesity and Overweight Veterans Everywhere! (MOVE!) program suggests that they can.
That research1, presented recently at the American Diabetes Association’s 73rd Scientific Sessions, along with similar positive data from VA’s own internal evaluations, leave the agency with one pressing question: How do they coax more veterans in need of lifestyle changes into the program?
Emory’s researchers in Atlanta looked at nationwide data from MOVE!, which has enrolled more than 400,000 veterans since 2005, making it the largest lifestyle change program in the United States.
VA’s electronic medical record system allowed the researchers to look at a lifestyle change program in the real world instead of in a controlled trial setting. While other intensive lifestyle change programs, such as the Diabetes Prevention Program, also have been proven successful, those studies have involved research volunteers who, by their very volunteering as research subjects, were more highly motivated than the average patient.
“We know little about what can be achieved in healthcare settings where participants are patients who are recommended to take action, not study volunteers,” said Sandra Jackson, a PhD candidate in Nutrition and Health Sciences, whose dissertation is focusing on this issue. “We believe the [MOVE!] program is an incredible innovation, and we are excited to study its impacts on veterans’ health.”
Of the 400,000 participants, Jackson and her colleagues identified 130,000 who had three years of follow-up. Participants were found to have lost a modest amount of weight and maintained it over time — an average of 1.3% of their total weight over three years. More involved participants, with at least eight sessions in six months, experienced an average 2.7% loss of body weight.
Jackson and her colleagues continue to examine the data, including identifying patient factors that contributed to success or failure in MOVE!.
“Our analyses are ongoing, and we’re beginning to research this now,” Jackson said. “We know that participants who already had diabetes participated more actively in the program and lost more weight than those without diabetes. And participants with a higher baseline BMI also lost more weight than those with lower baseline BMI.”
About 38% of participants already had diabetes when coming into the program. Those veterans were more likely to actively participate in the program and lose more weight. Those who did not have diabetes and lost weight by the six-month mark, were less likely to develop diabetes over three years. That drop in risk increased for every pound lost — with each additional pound equating to roughly 1% less risk of developing type 2 diabetes.
Conversation About Weight
With 77% of the roughly 3.5 million veterans screened each year coming up positive for diabetes or for an unhealthy amount of excess weight, the challenge for VA now is how to get as many patients as possible into MOVE!. The voluntary nature that made it so fascinating for Emory’s researchers also means that veterans cannot be forced into joining the program.
Furthermore, weight loss can be a touchy subject for patients and, if not approached carefully, a veteran may choose to ignore a physicians’ recommendation rather than deal openly with the issue.
A new tool from VA has been designed to help physicians with this conversation. The Moving Veterans to MOVE! tool is a simple five-step procedure that maps out the steps physicians should take when broaching the subject of weight loss with a patient.
“It’s about motivational interviewing,” explained Kenneth Jones, PhD, VA’s National Program Director for Weight Management. “The physician acknowledges that the patient is in control. Often they are well-informed about what their next step should be, and you want to be very respectful with patients.”
Step One has the physician ask the patient’s permission to talk about weight.
“Clinicians are often uncomfortable bringing this up,” Jones said. This first step is to say something along the lines of: ‘I see from your chart that your weight is higher than we would expect, given your height. Would it be OK if I talked to you about your weight?’”
If the patient agrees, the physician continues. If patients refuse, they are told that, whenever they want to discuss it, their VA healthcare team will be there to listen and help.
The next two steps direct the physician to ask the veteran about current or previous efforts to lose weight. Because a lot of patients would have attempted weight management before, it’s important for the physician to acknowledge that and to support those efforts.
The fourth step is to share information about MOVE!. Again, physicians ask permission before doing this, giving patients every opportunity to stop the discussion if they feel uncomfortable and imbuing them greater control of the experience.
If, after hearing about MOVE!, patients ask to become a participant, physicians will make a referral to the program.
“It’s really common that [when] we ask a veteran to come into MOVE! that they decline,” Jones said. “One of the things we’ve trained the clinicians to understand is that it’s OK to say to patients, ‘If you change your mind on that, let us know and you can come into MOVE! in the future.’”
Quite often, Jones said, those veterans come back some time later, having given more thought to MOVE!, and ask to be a part of the program.