Association Between a National Behavioral Weight Management Program and Veterans Affairs Health Expenditures.

OBJECTIVE: The association between participation in a behavioral weight intervention and health expenditures has not been well characterized. We compared Veterans Affairs (VA) expenditures of individuals participating in MOVE!, a VA behavioral weight loss program, and matched comparators 2 years before and 2 years after MOVE! initiation. METHODS: Retrospective cohort study of Veterans who had one or more MOVE! visits in 2008-2017 who were matched contemporaneously to up to 3 comparators with overweight or obesity through sequential stratification on an array of patient characteristics, including sex. Baseline patient characteristics were compared between the two cohorts through standardized mean differences. VA expenditures in the 2 years before MOVE! initiation and 2 years after initiation were modeled using generalized estimating equations with a log link and distribution with variance proportional to the standard deviation (gamma). RESULTS: MOVE! participants (n=499,696) and comparators (n=1,336,172) were well-matched, with an average age of 56, average body mass index of 35, and similar total VA expenditures in the fiscal year before MOVE! initiation ($9662 for MOVE! participants and $10,072 for comparators, standardized mean difference=-0.019). MOVE! participants had total expenditures that were statistically lower than matched comparators in the 6 months after initiation but modestly higher in the 6 months to 2 years after initiation, though differences were small in magnitude (1.0%-1.6% differences). CONCLUSIONS: The VA's system-wide behavioral weight intervention did not realize meaningful short-term health care cost savings for participants.

Black Veterans Experiences with and Recommendations for Improving Weight-Related Health Care: A Photovoice Study.

BACKGROUND: Non-Hispanic Black or African American (hereafter Black) veterans lose less weight than other users of the Veterans Health Administration's (VHA) weight management program (MOVE!), despite higher enrollment. OBJECTIVE: To understand factors that affect weight loss disparities between Black veterans and other veterans. DESIGN: Qualitative study using Photovoice methods. PARTICIPANTS: Self-identified Black veterans in MOVE! across the USA (two women, seven men). APPROACH: We conducted six virtual Photovoice sessions with Black veterans. Session one provided orientation to the goal of understanding factors that might affect weight loss disparities. Participants chose missions related to weight management and VHA care, bringing photos or other media (e.g., poems) to discuss during remaining sessions. Facilitators/participants identified themes related to each session in real time. Between and after sessions, facilitators/investigators conducted rapid qualitative analysis of transcripts/audio to group similar themes, identify illustrative quotes/photos/other media, and prepare dissemination products (e.g., this manuscript). Participants provided feedback on the manuscript during an additional session. KEY RESULTS: Themes were identified across three categories: (1) Food in Our Lives and Health Care; (2) Body Image; and (3) Healthcare Bias and Discrimination. The emotional impact of food and the negative effects of bias and discrimination on health care quality and trust were especially salient. Participants provided recommendations for weight-related and general care. Notable recommendations included the need for VHA to hire and retain providers-especially Black providers-who understand and respect Black patients and are committed to delivering evidence-based, culturally sensitive care. In addition, weight management care should be tailored to individual patients' diets and health beliefs and deemphasize body mass index. CONCLUSIONS: Photovoice resulted in concrete targets that could reduce health disparities. Institutions should consider Photovoice and similar approaches to build trust with and incorporate input from marginalized communities. This approach requires sustained commitment from leaders to engage stakeholders and implement solutions.

Real World Use of Anti-Obesity Medications and Weight Change in Veterans.

BACKGROUND: Anti-obesity medications (AOMs) can be initiated in conjunction with participation in the VA national behavioral weight management program, MOVE!, to help achieve clinically meaningful weight loss. OBJECTIVE: To compare weight change between Veterans who used AOM + MOVE! versus MOVE! alone and examine AOM use, duration, and characteristics associated with longer duration of use. DESIGN: Retrospective cohort study using VA electronic health records. PARTICIPANTS: Veterans with overweight or obesity who participated in MOVE! from 2008-2017. MAIN MEASURES: Weight change from baseline was estimated using marginal structural models up to 24 months after MOVE! initiation. The probability of longer duration of AOM use (≥ 180 days) was estimated via a generalized linear mixed model. RESULTS: Among MOVE! participants, 8,517 (1.6%) used an AOM within 24 months after MOVE! initiation with a median of 90 days of cumulative supply. AOM + MOVE! users achieved greater weight loss than MOVE! alone users at 6 (3.2% vs. 1.6%, p < 0.001), 12 (3.4% vs. 1.4%, p < 0.001), and 24 months (2.7% vs. 1.5%, p < 0.001), and had a greater probability of achieving ≥ 5% weight loss at 6 (38.8% vs. 26.0%, p < 0.001), 12 (43.1% vs. 28.4%, p < 0.001), and 24 months (40.4% vs. 33.3%, p < 0.001). Veterans were more likely to have ≥ 180 days of supply if they were older, exempt from medication copays, used other medications with significant weight-gain, significant weight-loss, or modest weight-loss side effects, or resided in the West North Central or Pacific regions. Veterans were less likely to have ≥ 180 days of AOM supply if they had diabetes or initiated MOVE! later in the study period. CONCLUSIONS: AOM use following MOVE! initiation was uncommon, and exposure was time-limited. AOM + MOVE! was associated with a higher probability of achieving clinically significant weight loss than MOVE! alone.

BMI Trends for Veterans Up to 10 Years After VA Enrollment Following Military Discharge.

BACKGROUND: Obesity (body mass index [BMI]≥30kg/m2) among US adults has tripled over the past 45 years, but it is unclear how this population-level weight change has occurred. OBJECTIVE: We sought to identify distinct long-term BMI trajectories and examined associations with demographic and clinical characteristics. DESIGN: The design was latent trajectory modeling over 10 years of a retrospective cohort. Subgroups were identified via latent class growth mixture models, separately by sex. Weighted multinomial logistic regressions identified factors associated with subgroup membership. PARTICIPANTS: Participants were a retrospective cohort of 292,331 males and 62,898 females enrolled in VA. MAIN MEASURES: The main outcome measure was 6-month average VA-measured BMI over the course of 10 years. Additional electronic health record measures on demographic, clinical, and services utilization characteristics were also used to characterize latent trajectories. KEY RESULTS: Four trajectories were identified for men and for women, corresponding to standard BMI categories "normal weight" (BMI <25), "overweight" (BMI 25-29.99), and "with obesity" (BMI ≥30): "normal weight" and increasing (males: 28.4%; females: 22.8%), "overweight" and increasing (36.4%; 35.6%), "with obesity" and increasing (33.6%; 40.0%), and "with obesity" and stable (males: 1.6%) or decreasing (females: 1.6%). Race, ethnicity, comorbidities, mental health diagnoses, and mental health service utilization discriminated among classes. CONCLUSIONS: BMI in the 10 years following VA enrollment increased modestly. VA should continue prioritizing weight management interventions to the large number of veterans with obesity upon VA enrollment, because the majority remain with obesity.

The Impact of the COVID-19 Pandemic on Mental Health, Occupational Functioning, and Professional Retention Among Health Care Workers and First Responders.

BACKGROUND: The COVID-19 pandemic has greatly affected front-line health care workers (HCW) and first responders (FR). The specific components of COVID-19 related occupational stressors (CROS) associated with psychiatric symptoms and reduced occupational functioning or retention remain poorly understood. OBJECTIVES: Examine the relationships between total and factored CROS, psychiatric symptoms, and occupational outcomes. DESIGN: Observational, self-report, single time-point online assessment. PARTICIPANTS: A total of 510 US HCW (N = 301) and FR (N = 200) with occupational duties affected by the COVID-19 pandemic. MAIN OUTCOMES AND MEASURES: CROS were assessed using a custom 17-item questionnaire. Post-traumatic stress disorder (PTSD), depression, insomnia, and generalized anxiety symptoms were assessed using the PTSD Checklist-5 (PCL5), Patient Health Questionnaire-9 (PHQ9), Insomnia Severity Index (ISI), and General Anxiety Disorder-7 (GAD7). Respondents' likelihood of leaving current field and occupational functioning were assessed with 2-item PROMIS subscales. Relationships were modeled using multivariable regression. Open-ended responses were coded using rapid template analysis. RESULTS: CROS total scores correlated significantly with all four psychiatric symptom domains (R's = .42-.53), likelihood of leaving one's current occupation (R = .18), and trouble doing usual work (R = .28), all p's < .001. Half of HCW indicated a decreased likelihood of staying in their current occupation as a result of the pandemic. CROS were fit to a 3-factor model consisting of risk, demoralization, and volume factors. All CROS factors were associated with psychiatric symptom burden, but demoralization was most prominently associated with psychiatric symptoms and negative occupational outcomes. Among psychiatric symptoms, PTSD symptoms were most strongly associated with negative occupational outcomes. Open-ended statements emphasized lack of protection and support, increased occupational demands, and emotional impact of work duties. CONCLUSIONS AND RELEVANCE: These results demonstrate potentially treatable psychiatric symptoms in HCW and FR experiencing CROS, impacting both wellbeing and the health care system. Mitigating CROS, particularly by addressing factors driving demoralization, may improve HCW and FR mental health, occupational functioning, and retention.

"No One Should Feel Like They're Unsafe": Mobility Justice Photovoice as a Youth Advocacy Tool for Equitable Community Mobility.

Mobility is an often overlooked social determinant of health that broadly affects people of color's health. This study aimed to examine personal and community mobility challenges and opportunities among youth of color and partner to advance equitable community mobility. We conducted a community-based participatory research photovoice study using mobility justice principles from November 2020 to May 2021 with 10 youth of color from South Seattle, Washington. We conducted thematic content analysis of verbatim transcripts. Youth recommended infrastructure changes and free transit to facilitate safe, accessible mobility. Youth reported feeling vulnerable riding public transit alongside people experiencing mental health issues, while recognizing the dangers police can bring to people with mental health challenges and/or communities of color. They emphasized the importance of youth voice and intergenerational community discussions to inform policy making. We coorganized an online forum with youth to exchange ideas for advancing equitable mobility with their community and city leaders. Youth expressed feeling empowered and deepening dedication to mobility justice. Leaders should implement policy and infrastructure changes to enhance equitable mobility by incorporating youth and mobility justice principles in decision-making processes, pay youth for their time, employ facilitators of color, and offer technology support.

National Veterans Health Administration MOVE! Weight Management Program Participation During the COVID-19 Pandemic.

INTRODUCTION: In response to COVID-19, the Veterans Health Administration (VHA) converted appropriate outpatient visits to virtual care, including MOVE! Weight Management Program for Veterans (MOVE!) visits. Before the pandemic, most veterans participated in MOVE! in person, with several telehealth modalities available. We sought to describe national trends in MOVE! participation during the pandemic (March 2020-January 2021) overall and by modality and to compare participation to prepandemic levels. METHODS: We conducted a national retrospective cohort study of veterans who participated in MOVE! from January 2018 through January 2021. We examined MOVE! participation across VHA aggregated at the national level by month, including the number of visits, participants, and new participants in person and via telehealth, including telephone, clinic-to-clinic synchronous video, anywhere-to-anywhere (eg, provider home to patient home) synchronous video, and remote education and monitoring. We also determined the percentage of all MOVE! visits attributable to each modality and the monthly percentage change in participation during the pandemic compared with monthly averages in prior years. RESULTS: Before March 2020, 20% to 30% of MOVE! was delivered via telehealth, which increased to 90% by April 2020. Early in the pandemic, telephone-delivered MOVE! was the most common modality, but anywhere-to-anywhere synchronous video participation increased over time. Compared with the same months in prior years, total monthly MOVE! participation remained 20% to 40% lower at the end of 2020 and into January 2021. CONCLUSION: The VHA MOVE! program rapidly shifted to telehealth delivery of weight management services in response to the pandemic. However, a gap remained in the number of veterans receiving these services compared with prior years, suggesting potential unmet needs for weight management.

Effect of a Remotely Delivered Self-directed Behavioral Intervention on Body Weight and Physical Health Status Among Adults With Obesity: The D-ELITE Randomized Clinical Trial.

Importance: The effectiveness of remotely delivered, self-directed, weight loss programs in routine clinical practice is largely unknown. Objective: To test whether a self-directed, remotely administered behavioral lifestyle intervention improves weight and self-reported general health status compared with usual care. Design, Setting, and Participants: In this randomized clinical trial, 511 adults with a body mass index (BMI) of 30 or more and less than 45 (based on electronic health record [EHR] weight and height), were enrolled from 30 Veterans Health Administration (VHA) sites between February 15, 2018, and December 18, 2018 (final follow-up February 18, 2021). Interventions: Participants were randomly assigned to the intervention group (n = 254) or the control group (n = 257). Both received usual care. Participants randomized to the intervention received Diabetes Prevention Program-based self-directed videos, handouts, and coaching messages via an online platform or US mail for 12 months. Main Outcomes and Measures: Coprimary outcomes were weight measured in primary care and recorded in the EHR and self-reported general health status using the Medical Outcomes Study 12-Item Short Form Health Survey (SF-12) physical component score (PCS; higher scores are better [range, 0-100]) at the 12-month follow-up. The between-group minimal clinically important differences are 3 kg for weight and 5 points for the SF-12 PCS. Linear mixed models used weights and SF-12 PCS measured at either time point, with participants analyzed according to randomization assignment. Statistical significance for each coprimary outcome was based on a 2-sided α level of .025. Results: Among 511 participants randomized (mean age, 57.4 [SD, 13.9] years; 231 female [45%]), 429 (84.0%) had EHR-based weights and 410 (80.2%) had SF-12 PCS data at 12 months. The unadjusted mean weight at 12 months declined from 102.7 kg to 99.8 kg in the intervention group compared with 101.9 kg to 101.0 kg in the control group (adjusted between-group mean difference, -1.93 [97.5% CI, -3.24 to -0.61]; P = .001). At 12 months, the unadjusted mean SF-12 PCS scores declined from 44.8 to 44.3 among intervention participants compared with 44.5 to 43.2 among control participants (adjusted between-group mean difference, intervention minus control, 0.69 [97.5% CI, -1.11 to 2.49]; P = .39). Cardiovascular events represented the highest percentage of serious adverse events, accounting for 25% of events in the intervention group and 35% in the control group. Conclusions and Relevance: Among adults with obesity, a remotely delivered self-directed, behavioral lifestyle intervention, compared with usual care, resulted in statistically significantly greater weight loss at 12 months, although the difference was not clinically important. There was no significant difference in self-reported general physical health status at 12 months. Trial Registration: ClinicalTrials.gov Identifier: NCT03260140.

Differences in functional and structural social support among female and male veterans and civilians.

PURPOSE: Social support is an important correlate of health behaviors and outcomes. Studies suggest that veterans have lower social support than civilians, but interpretation is hindered by methodological limitations. Furthermore, little is known about how sex influences veteran-civilian differences. Therefore, we examined veteran-civilian differences in several dimensions of social support and whether differences varied by sex. METHODS: We performed a cross-sectional analysis of the 2012-2013 National Epidemiologic Survey of Alcohol and Related Conditions-III, a nationally representative sample of 34,331 respondents (male veterans = 2569; female veterans = 356). We examined veteran-civilian differences in functional and structural social support using linear regression and variation by sex with interactions. We adjusted for socio-demographics, childhood experiences, and physical and mental health. RESULTS: Compared to civilians, veterans had lower social network diversity scores (difference [diff] = - 0.13, 95% confidence interval [CI] - 0.23, - 0.03). Among women but not men, veterans had smaller social network size (diff = - 2.27, 95% CI - 3.81, - 0.73) than civilians, attributable to differences in religious groups, volunteers, and coworkers. Among men, veterans had lower social network diversity scores than civilians (diff = - 0.13, 95% CI - 0.23, - 0.03); while among women, the difference was similar but did not reach statistical significance (diff = - 0.13, 95% CI - 0.23, 0.09). There was limited evidence of functional social support differences. CONCLUSION: After accounting for factors that influence military entry and social support, veterans reported significantly lower structural social support, which may be attributable to reintegration challenges and geographic mobility. Findings suggest that veterans could benefit from programs to enhance structural social support and improve health outcomes, with female veterans potentially in greatest need.

Healthy Teaching Kitchen Programs: Experiential Nutrition Education Across Veterans Health Administration, 2018.

Traditional clinical interventions yield few positive effects on diet. The Healthy Teaching Kitchen (HTK) program implemented by the Veterans Health Administration at sites across the United States delivers interactive nutrition and culinary education, guided instruction, and social opportunities for patients and caregivers. We report HTK outcomes of veterans' self-reported acceptability, self-efficacy for dietary change, and dietary and cooking habits. The HTK program is acceptable and feasible and may empower participants to improve health.

The relationships of posttraumatic stress disorder and depression symptoms with health-related quality of life and the role of social support among Veterans.

PURPOSE: The presence of posttraumatic stress disorder (PTSD) or depression symptoms is associated with poor quality of life. Social support buffers against developing symptoms of PTSD and depression and is associated with greater quality of life. We examined the relationships between PTSD and depression symptom severity with physical (PCS) and mental (MCS) health-related quality of life (HRQoL), and whether social support moderated these relationships. METHODS: Randomly selected Veterans with at least one Primary Care or PTSD Clinical Team visit received a mailed survey including self-report measures of health and wellness. Among the 717 respondents, we examined the association between symptom severity and HRQoL using linear regression. We included interaction terms between symptom severity and social support to examine whether social support moderated these associations. RESULTS: Social support did not moderate the association between symptom severity and mental HRQoL. Higher PTSD and depression symptom severity were associated with lower MCS scores, whereas higher social support was associated with higher MCS scores. When examining physical HRQoL, social support moderated the association with PTSD and depression symptom severity. Among individuals with high social support, there was a negative association between symptom severity and PCS scores, whereas there was no association among those with low social support. CONCLUSIONS: Although there are contexts in which social support is helpful, in some cases it may interfere with HRQoL among those with mental health conditions. Thus, it is important to educate support providers about behaviors that enhance the benefits and minimize the costs of social support.

Post-traumatic stress disorder, physical activity, and eating behaviors.

Post-traumatic stress disorder (PTSD), a prevalent and costly psychiatric disorder, is associated with high rates of obesity and cardiometabolic diseases. Many studies have examined PTSD and risky behaviors (e.g., smoking, alcohol/substance abuse); far fewer have examined the relationship between PTSD and health-promoting behaviors. Physical activity and eating behaviors are 2 lifestyle factors that impact cardiometabolic risk and long-term health. This comprehensive review of the literature (1980-2014) examined studies that reported physical activity and eating behaviors in adults with PTSD or PTSD symptoms. A systematic search of electronic databases identified 15 articles on PTSD-physical activity and 10 articles on PTSD-eating behaviors in adults. These studies suggest that there may be a negative association among PTSD, physical activity, and eating behaviors. Preliminary evidence from 3 pilot intervention studies suggests that changes in physical activity or diet may have beneficial effects on PTSD symptoms. There was considerable heterogeneity in the study designs and sample populations, and many of the studies had methodological and reporting limitations. More evidence in representative samples, using multivariable analytical techniques, is needed to identify a definitive relationship between PTSD and these health behaviors. Intervention studies for PTSD that examine secondary effects on physical activity/eating behaviors, as well as interventions to change physical activity/eating behaviors that examine change in PTSD, are also of interest.

A pilot trial of telephone-based collaborative care management for PTSD among Iraq/Afghanistan war veterans.

BACKGROUND: Collaborative care and care management are cornerstones of Primary Care-Mental Health Integration (PC-MHI) and have been shown to reduce depressive symptoms. Historically, the standard of Veterans Affairs (VA) collaborative care was referring patients with posttraumatic stress disorder (PTSD) to specialty care. Although referral to evidence-based specialty care is ideal, many veterans with PTSD do not receive such care. To address this issue and reduce barriers to care, VA currently recommends veterans with PTSD be offered treatment within PC-MHI as an alternative. The current project outlines a pilot implementation of an established telephone-based collaborative care model-Translating Initiatives for Depression into Effective Solutions (TIDES)-adapted for Iraq/Afghanistan War veterans with PTSD symptoms (TIDES/PTSD) seen in a postdeployment primary care clinic. MATERIALS AND METHODS: Structured medical record extraction and qualitative data collection procedures were used to evaluate acceptability, feasibility, and outcomes. RESULTS: Most participants (n=17) were male (94.1%) and white (70.6%). Average age was 31.2 (standard deviation=6.4) years. TIDES/PTSD was successfully implemented within PC-MHI and was acceptable to patients and staff. Additionally, the total number of care manager calls was positively correlated with number of psychiatry visits (r=0.63, p<0.05) and amount of reduction in PTSD symptoms (r=0.66, p<0.05). Overall, participants in the pilot reported a significant reduction in PTSD symptoms over the course of the treatment (t=2.87, p=0.01). CONCLUSIONS: TIDES can be successfully adapted and implemented for use among Iraq/Afghanistan veterans with PTSD. Further work is needed to test the effectiveness and implementation of this model in other sites and among veterans of other eras.

Unique PTSD clusters predict intention to seek mental health care and subsequent utilization in US veterans with PTSD symptoms.

Many veterans return from deployment with posttraumatic stress disorder (PTSD), but most attend only a limited number of mental health care visits. Although global PTSD relates to seeking mental health care, it is unclear whether specific features of PTSD inform the low rates of mental health care utilization. This study examined PTSD cluster severities of avoidance, reexperiencing, dysphoria, and hyperarousal as predictors of intention to seek mental health care and prospective treatment utilization. US veterans with at least subthreshold PTSD (N = 189) completed a PTSD symptom measure and indicated whether they intended to seek mental health care. Prospective Department of Veterans Affairs mental health care utilization was extracted from the medical record. At the bivariate level, each cluster was positively associated with a positive intention to seek mental health care and prospective treatment utilization. In multivariate models, however, dysphoria severity (OR = 1.16, 95% CI [1.06, 1.26]) was uniquely and positively correlated with intention to seek mental health care, whereas higher avoidance severity (IRR = 0.86, 95% CI [0.76, 0.98]) predicted lower treatment utilization, and higher reexperiencing severity (IRR = 1.07, 95% CI [1.01, 1.14]) predicted greater treatment utilization. It is critical to tailor interventions to target specific features of PTSD and to meet patients where they are.

Differences in healthcare costs over 10 years following discharge from military service by weight trajectory.

The prevalence of overweight and obesity among military personnel has increased substantially in the past two decades. Following military discharge many personnel can receive integrated health care from the Veterans Health Administration. Prior research related to the economic impacts of obesity has not examined health care costs following the transition into civilian life following military discharge. To address this evidence gap, this study sought to compare longitudinal costs over 10 years across weight categories among VA enrollees recently discharged from the military.

Association between a national behavioral weight management program and real-world weight change.

OBJECTIVE: In a national cohort of Veterans, weight change was compared between participants in a US Department of Veterans Affairs (VA) behavioral weight management program (MOVE!) and matched non-participants, and between high-intensity and low-intensity participants. METHODS: Retrospective cohort study of Veterans with 1 + MOVE! visits in 2008-2017 were matched to MOVE! non-participants via sequential stratification. Percent weight change up to two years after MOVE! initiation of participants and non-participants was modeled using generalized additive mixed models, and 1-year weight change of high-intensity or low-intensity participants was also compared. RESULTS: MOVE! participants (n = 499,696) and non-participant controls (n = 1,336,172) were well-matched, with an average age of 56 years and average BMI of 35. MOVE! participants lost 1.4 % at 12 months and 1.2 % at 24 months, which was 0.89 % points (95 % CI: 0.83-0.96) more at 12 months than non-participants and 0.55 % points (95 % CI: 0.41-0.68) more at 24 months. 9.1 % of MOVE! participants had high-intensity use in one year, and they had 2.38 % point (95 % CI: 2.25-2.52) greater weight loss than low-intensity participation at 12 months (2.8 % vs 0.4 %). CONCLUSIONS: Participation in VA's system-wide behavioral weight management program (MOVE!) was associated with modest weight loss, suggesting that program modifications are needed to increase Veteran engagement and program effectiveness. Future research should further explore how variations in program delivery and the use of newer anti-obesity medications may impact the program's effectiveness.

Readiness for change predicts VA Mental Healthcare utilization among Iraq and Afghanistan war veterans.

Many veterans present to Veteran Affairs (VA) care intending to seek mental health treatment for symptoms of posttraumatic stress disorder (PTSD), depression, and/or alcohol misuse, yet most subsequently underutilize mental health care. This study examined the association of readiness for change with outpatient VA mental health care utilization in 104 treatment-seeking Iraq and Afghanistan war veterans who screened positive for PTSD, depression, and/or alcohol misuse at intake. Multivariate analyses demonstrated that readiness for change assessed at intake was positively associated (Incident Rate Ratio [IRR] = 1.22) with prospective outpatient mental health care utilization with demographic factors, military characteristics, and mental health burden in the model. Results suggest that interventions that target readiness to change, such as motivational interviewing, may improve treatment utilization in veterans presenting for mental health care.

Protocol for a pragmatic trial testing a self-directed lifestyle program targeting weight loss among patients with obstructive sleep apnea (POWER Trial).

BACKGROUND: Obesity comprises the single greatest reversible risk factor for obstructive sleep apnea (OSA). Despite the potential of lifestyle-based weight loss services to improve OSA severity and symptoms, these programs have limited reach. POWER is a pragmatic trial of a remote self-directed weight loss care among patients with OSA. METHODS: POWER randomizes 696 patients with obesity (BMI 30-45 kg/m2) and recent diagnosis or re-confirmation of OSA 1:1 to either a self-directed weight loss intervention or usual care. POWER tests whether such an intervention improves co-primary outcomes of weight and sleep-related quality of life at 12 months. Secondary outcomes include sleep symptoms, global ratings of change, and cardiovascular risk scores. Finally, consistent with a hybrid type 1 approach, the trial embeds an implementation process evaluation. We will use quantitative and qualitative methods including budget impact analyses and qualitative interviews to assess barriers to implementation. CONCLUSIONS: The results of POWER will inform population health approaches to the delivery of weight loss care. A remote self-directed program has the potential to be disseminated widely with limited health system resources and likely low-cost.

Use of conventional care and complementary/alternative medicine among US adults with arthritis.

OBJECTIVE: Managing arthritis and co-morbid conditions is of public health importance. It is therefore critical to have a comprehensive understanding of healthcare utilization among US adults with arthritis. Thus, the present study identified characteristics associated with using both complementary and alternative medicine (CAM) and conventional healthcare. METHOD: Using 2007 National Health Interview Survey data, multinomial logistic regression was performed to compare four categories of past year healthcare use (both CAM and conventional care vs. conventional care only, CAM only, and no healthcare use) on their potential correlates. RESULTS: The sample (n=3850) was 62.8% female and 80.4% non-Hispanic White. Nearly half were at least 65 years old, and had used both CAM and conventional services in the previous year. The following characteristics were associated with having used neither CAM nor conventional care in the previous year (vs. having used both CAM and conventional care): being from an ethnic and racial minority group (ORs=2.44, 3.26, and 3.91) and being uninsured (OR=4.06), identifying individuals potentially at risk for unmet need. CONCLUSION: To ensure access to comprehensive care, potentially underserved populations should be targeted with outreach (e.g., providing low-cost, accessible care, and education about benefits of various treatments for arthritis and co-morbid conditions).

Mental health and somatic symptom severity are associated with reduced physical activity among US Iraq and Afghanistan veterans.

OBJECTIVE: Ensuring that Iraq and Afghanistan veterans engage in adequate physical activity is essential to prevent metabolic and cardiovascular diseases, and promote psychological well-being. Identifying factors associated with physical activity in this population will yield areas for targeted interventions aimed at increasing activity. METHOD: Correlates of meeting physical activity recommendations (≥ 150 min/week of moderate-to-vigorous physical activity [MVPA]) were examined in Iraq/Afghanistan veterans assessed at intake to VA Puget Sound Healthcare System's post-deployment health clinic (May, 2005-August, 2009; N=266). RESULTS: The majority were male (94.3%) and Caucasian (70.7%), with an average age of 29.8 (SD=7.3) years. Participants engaged in a median of 180 weekly MVPA minutes. Among those meeting (59%) and not meeting (41%) recommendations, median weekly MVPA minutes were 540 and 0, respectively. In multivariate regression models, higher levels of depression (p=.042) and somatic (p=.018) symptom severity were associated with significantly decreased odds of meeting physical activity recommendations. CONCLUSION: Overall, physical activity engagement among Iraq/Afghanistan veteran VA patients was above the level specified in national recommendations. Those with higher depressive and somatic symptoms were less likely to meet physical activity recommendations and may benefit from targeted physical activity promotion interventions.