November 10, 2021
Lalitha Kambhamettu, MD
Obesity affects members who served in the US Military (US veterans) at a higher rate than the general population. Military enlists are a pre-selected group of healthy people who meet physical and mental fitness standards of the Department of Defense (DoD). US veterans are a unique group of individuals with characteristics related to their service as elaborated below, that places them at high risk for obesity and related chronic conditions such as coronary heart disease, cancer, COPD, diabetes, arthritis and depressive disorders. Often, this results in poorer health status and increased disability compared to the general population after completion of their period of service (Betancourt, et al, 2000). Such findings raise a sense of alarm, responsibility and urgency to address the specific health-care needs of this population subset. High morbidity and high cost of chronic disease management also serve as an impetus for further research and development of additional tools in caring for the nearly 800,000 veterans who meet the BMI criteria for severe obesity [Body Mass Index (BMI) >/=35Kg/m2] that are currently receiving care at the Veterans Health Administration (VHA) healthcare system.
Military experience, ranging from rigor of basic training, deployment to overseas missions, participation in combat operations, exposure to environmental and chemical hazards, sustaining physical, psychological and sexual trauma can profoundly alter human behavior and impact health. In addition, undesirable dietary behaviors may be adopted during deployments such as eating freely available snacks that are calorie-dense and nutrient-poor at military base Dining Facility/Cafeteria (DFAC) to combat loneliness and boredom to consuming Meal Replacement Equivalents (MREs) while on the go for several weeks under conditions of high psychological stress and hot, cold, high altitude, desert type environments. Moreover, reintegrating into a self-structured lifestyle of civilian society after enduring the regimented military lifestyle can often leave ex-servicemen and women in need of new coping skills, especially in light of sustained trauma (Wischik, et al, 2019).
Obesity is a chronic, relapsing, multifactorial, neurobehavioral disease with complex interplay of individual, social and environmental factors. It has far-reaching health and healthcare ramifications. The additional angle of history of military service in an individual poses further challenges in the management of this condition. Often, addressal of subacute-acute symptoms such as musculoskeletal and neuropathic pain, mental health illnesses and/or crises, substance abuse disorders, uncontrolled diabetes and/or hypertension, medication non-adherence, homelessness and lack of social support takes precedence in the clinical setting, pushing back the addressal of obesity.
VHA along with National Center for Health Promotion and Disease Prevention (NCP) designed the MOVE! Program (Managing Overweight Veterans Everywhere) to assist veterans to lose weight and improve health. Every VA medical center has a MOVE! Coordinator in charge of conducting a 16-week evidence-based outpatient program designed to implement behavioral weight management. The MOVE! Coordinator is often supported by a team of clinical members including licensed social work, physical therapist, pharmacist and physician. Veterans are often required to participate in the MOVE! Program to become eligible for anti-obesity medications and referral to bariatric surgery.
While available, evidence-based obesity treatments, including behavioral weight management, anti-obesity medications and bariatric surgery, are often underutilized in the VHA (Funk, et al, 2021). Related challenges may include lack of veteran awareness of risks of obesity or treatment options and motivation to pursue treatment along with particular patient demographics (predominantly older and male), limited availability of resources and barriers to referral (Gunnar, 2017). Lack of provider training (Forman-Hoffman et al, 2006) and allocation of time to specifically address obesity are also potentially limiting factors. Implementation of the MOVE! Program is variable within the VA system and interestingly, no two sites share the same condition pattern (Kahwati, et al, 2011).
Over the years, various studies have explored and identified different aspects of obesity in veterans including high risk groups such as black women veterans, women veterans with schizophrenia, Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native veterans (Breland, et al, 2017), biases against men with obesity compared to women veterans in relation to their health care experiences (Breland et al, 2019), and the underutilization of anti-obesity medications in veterans (Thomas, et al, 2019). These studies suggest that facility level MOVE! utilization rates ranging from 0.05 to 16% with higher likelihood of at least one MOVE! visit if veterans were female, unmarried, a minority, with higher BMI, or had a co-existing psychiatric or obesity-related comorbidity (Del Re, et al, 2013). Further research is needed to identify and overcome this condition among veterans across all demographics.
Resources currently available for clinicians:
VHA/DoD Clinical Practice Guideline for management of Adult Overweight and Obesity is an important resource for clinicians involved in care of veterans with obesity. The document is designed to provide information and assist decision-making.
MOVE! Program is VA’s national outpatient weight management program developed by National Center for Health promotion and Disease Prevention (NCP) and is offered free of charge to enrolled veterans. It is an evidence-based 16-week self-management program available at several VHA facilities nationwide. Every VA Medical center has a dedicated MOVE! Coordinator who assists veterans in their weight loss journey. Every participating veteran is provided with a free workbook as well as other tools.
Telephone Lifestyle Coaching (TLC) Program TLC is a free telephone-based coaching program where veterans receive education and support for goal-setting and action planning for personal health and self-care behaviors at their convenience from trained and experienced health coaches. This program requires referral from clinician at participating VA locations.
Anti-Obesity medications VA Pharmacy carries on formulary five anti-obesity medications, namely Phentermine, Liraglutide, Naltrexone/Bupropion, Orlistat and Phentermine/Topiramate to be used in conjunction with comprehensive lifestyle intervention. Anti-obesity medications are underutilized among veterans.
Bariatric surgery is presently offered to veterans at certain VHA facilities through the VISNs (Veteran Integrated Service Networks) This is currently an under-utilized tool of obesity management within the VA system with only 400-500 bariatric surgeries performed annually nationwide (Maciejewski et al, 2019).
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