Sleep Apnea Among Gulf War Veterans: An Examination of VA Utilization Rates, Treatment Initiation, and Health Outcomes.

OBJECTIVES: Obstructive sleep apnea (OSA) among veterans is frequently underdiagnosed and undertreated. The present study sought to: 1) characterize the prevalence and rate of treatment of OSA among VA users and non-users and 2) examine the associations between diagnosed or probable OSA and key physical and mental health outcomes. METHODS: Gulf-War I-era Veterans were recruited as part of a national survey assessing mental and physical health concerns, healthcare needs, and healthcare utilization. OSA diagnoses were self-reported while sleep apnea risk was assessed via the STOP-Bang. Veterans also completed questionnaires assessing overall health, pain, depression, PTSD, and psychosocial functioning. RESULTS: 1,153 veterans were included in the present analyses (Mean age = 58.81; 21.84% female). Compared to non-VA healthcare users, veterans receiving care at the VA were more likely to have been diagnosed with OSA (p < .001) and report receiving treatment for OSA (p = .005). Compared to veterans at low risk for OSA, veterans at elevated risk reported higher levels of pain (p = .001), depression (p = .02), and poorer psychosocial functioning (p < .001). CONCLUSIONS: OSA diagnoses appear to be more common among VA healthcare users. Findings suggest that OSA remains underdiagnosed and associated with important physical and mental health consequences. Additional screening for OSA, especially among non-VA clinics, is warranted.

Cannabis use and suicide risk among Gulf War veterans.

Cannabis use has been indicated as a risk factor for suicide in veterans. This study of Gulf War veterans tested the relationship between self-report past year cannabis use and (a) past year suicidal ideation and (b) risk for suicidal behavior. Data were from a national sample (N = 1126) of Gulf War veterans. Logistic regression models indicated cannabis use was associated with past year suicidal ideation and elevated risk for suicidal behavior, independent of key covariates. In corroboration with research on other military populations, this study indicates a potentially concerning association between cannabis use and suicide risk in Gulf War veterans.

The association of military sexual assault and nonsuicidal self-injury in U.S. Gulf War-I era veterans.

Military sexual assault (MSA) is a prevalent issue among military personnel that has been linked to adverse mental and physical health outcomes, including posttraumatic stress disorder (PTSD) and suicidal thoughts and behaviors. The present study sought to investigate the relationship between MSA and nonsuicidal self-injury (NSSI) in a national sample of Gulf War-I Era U.S. veterans. The study analyzed data from 1,153 Gulf War-I veterans collected through a cross-sectional survey that assessed demographic information, clinical outcomes, military background, and history of MSA and NSSI. MSA was found to be significantly associated with NSSI at the bivariate level (OR = 2.19, p < .001). Further, MSA remained significantly associated with NSSI (AOR = 2.50, p = .002) after controlling for relevant demographics and clinical outcomes. Veterans with a history of MSA were approximately two and half times more likely to engage in NSSI than veterans who had not experienced MSA. The present findings provide preliminary evidence linking MSA and NSSI. Further, the findings highlight the importance of assessing MSA and NSSI in veteran populations, particularly among those seeking treatment for PTSD.

Correlates and clinical associations of military sexual assault in Gulf War era U.S. veterans: Findings from a national sample.

Military sexual assault (MSA) is a prevalent issue among military personnel that can have direct implications on postmilitary mental health. Gulf War era U.S. veterans represent the first cohort in which women veterans were integrated into most aspects of military service except for combat. The present study sought to build on prior studies by identifying characteristics associated with the occurrence of MSA and clinical correlates of MSA and examining how these differ between men and women. This study analyzed cross-sectional survey data from a national sample of treatment-seeking Gulf War era veterans. Participants (N = 1,153) reported demographic information, clinical outcomes, military background, and history of MSA. MSA was more common among female veterans (n = 100, 41.3%) than male veterans (n = 32, 3.6%). The odds of experiencing MSA were approximately 19 times higher for female veterans relative to their male peers, OR = 18.92, p < .001. Moreover, as expected, MSA was robustly associated with probable current posttraumatic stress disorder, probable current depression, and past-year suicidal ideation in female veterans, whereas combat exposure was robustly associated with these sequelae in male veterans. The present findings confirm that a large proportion of female veterans from the Gulf War era experienced MSA and highlight the deleterious correlates of MSA on veterans' mental health. Sex differences of correlates of MSA and subsequent clinical associations are highlighted.

Persistent MRI Findings Unique to Blast and Repetitive Mild TBI: Analysis of the CENC/LIMBIC Cohort Injury Characteristics.

INTRODUCTION: MRI represents one of the clinical tools at the forefront of research efforts aimed at identifying diagnostic and prognostic biomarkers following traumatic brain injury (TBI). Both volumetric and diffusion MRI findings in mild TBI (mTBI) are mixed, making the findings difficult to interpret. As such, additional research is needed to continue to elucidate the relationship between the clinical features of mTBI and quantitative MRI measurements. MATERIAL AND METHODS: Volumetric and diffusion imaging data in a sample of 976 veterans and service members from the Chronic Effects of Neurotrauma Consortium and now the Long-Term Impact of Military-Relevant Brain Injury Consortium observational study of the late effects of mTBI in combat with and without a history of mTBI were examined. A series of regression models with link functions appropriate for the model outcome were used to evaluate the relationships among imaging measures and clinical features of mTBI. Each model included acquisition site, participant sex, and age as covariates. Separate regression models were fit for each region of interest where said region was a predictor. RESULTS: After controlling for multiple comparisons, no significant main effect was noted for comparisons between veterans and service members with and without a history of mTBI. However, blast-related mTBI were associated with volumetric reductions of several subregions of the corpus callosum compared to non-blast-related mTBI. Several volumetric (i.e., hippocampal subfields, etc.) and diffusion (i.e., corona radiata, superior longitudinal fasciculus, etc.) MRI findings were noted to be associated with an increased number of repetitive mTBIs versus. CONCLUSIONS: In deployment-related mTBI, significant findings in this cohort were only observed when considering mTBI sub-groups (blast mechanism and total number/dose). Simply comparing healthy controls and those with a positive mTBI history is likely an oversimplification that may lead to non-significant findings, even in consortium analyses.

Experiential Avoidance, Posttraumatic Stress Disorder, and Self-Injurious Thoughts and Behaviors: A Moderation Analysis in a National Veteran Sample.

Experiential avoidance (EA) is associated with posttraumatic stress disorder (PTSD) and self-injurious thoughts and behaviors (SITBs) across different populations, and extant literature has demonstrated a strong relationship between PTSD and SITBs. However, no study has explored the potential moderating role EA plays in the association of PTSD with nonsuicidal self-injury (NSSI), suicidal ideation, and suicide attempts. The objective of the present study was to determine if EA would moderate the association with PTSD and SITBs such that the association between PTSD and individuals SITBs would be stronger among individuals with higher EA. In a large national sample of Gulf War Era veterans (N = 1,138), EA was associated with PTSD, lifetime and past-year NSSI, current suicidal ideation, and lifetime suicide attempts in bivariate analyses. Multivariate analyses detected a significant EA by PTSD interaction on lifetime NSSI (AOR = 0.96), past-year NSSI (AOR = 1.03), and suicide attempts (AOR =1.03). Probing of the interactions revealed that the respective associations between PTSD, lifetime and past-year NSSI, and suicide attempts were stronger at lower levels of EA (i.e., better), counter to our hypotheses. These preliminary findings contextualize the relationship between these variables in a Gulf War veterans sample and signal the need to further investigate these relationships. Further, these findings highlight the need for advancement in assessment and intervention of EA and SITBs.

Comparing psychosocial functioning, suicide risk, and nonsuicidal self-injury between veterans with probable posttraumatic stress disorder and alcohol use disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are each common among Unites States (U.S.) military veterans and frequently co-occur (i.e., PTSD+AUD). Although comorbid PTSD+AUD is generally associated with worse outcomes relative to either diagnosis alone, some studies suggest the added burden of comorbid PTSD+AUD is greater relative to AUD-alone than to PTSD-alone. Furthermore, nonsuicidal self-injury (NSSI) is more common among veterans than previously thought but rarely measured as a veteran psychiatric health outcome. This study sought to replicate and extend previous work by comparing psychosocial functioning, suicide risk, and NSSI among veterans screening positive for PTSD, AUD, comorbid PTSD+AUD, and neither disorder. METHODS: This study analyzed data from a national sample of N = 1046 U.S. veterans who had served during the Gulf War. Participants self-reported sociodemographic, functioning, and clinical information through a mailed survey. RESULTS: Veterans with probable PTSD+AUD reported worse psychosocial functioning across multiple domains compared to veterans with probable AUD, but only worse functioning related to controlling violent behavior when compared to veterans with probable PTSD. Veterans with probable PTSD+AUD reported greater suicidal ideation and NSSI than veterans with probable AUD, but fewer prior suicide attempts than veterans with probable PTSD. LIMITATIONS: This study was cross-sectional, relied on self-report, did not verify clinical diagnoses, and may not generalize to veterans of other military conflicts. CONCLUSIONS: Findings underscore the adverse psychiatric and functional outcomes associated with PTSD and comorbid PTSD+AUD, such as NSSI, and highlight the importance of delivering evidence-based treatment to this veteran population.

Experiential Avoidance, Pain, and Suicide Risk in a National Sample of Gulf War Veterans.

Objective: Pain confers risk for suicidal thoughts and behaviors. Experiential avoidance (EA), which is relevant to both pain and suicide risk, has not been studied as a potential mechanism for this relationship. The present study tested the hypothesis that pain indirectly impacts suicide risk through EA in a national sample of Gulf War veterans.Methods: Participants included a stratified random sample of United States veterans (N = 1,012, 78% male) who had served in the Gulf War region between August 1990 and July 1991. Validated scales were used to quantify levels of pain, EA, and suicide risk.Results: Regression analyses indicated independent associations between pain, EA, and suicide risk; moreover, the association between pain and suicide risk was no longer significant once EA was included in model. Bootstrapping analyses confirmed that EA partially accounted for the cross-sectional association between pain and suicide risk, independent of common co-occurring problems, such as depression, PTSD, and alcohol use disorder symptoms.Conclusions: EA could be a key modifiable risk factor to target in people experiencing pain.

A pilot survey of post-deployment health care needs in small community-based primary care clinics.

BACKGROUND: Relatively little is known regarding to what extent community-based primary care physicians are encountering post-deployment health care needs among veterans of the Afghanistan or Iraq conflicts and their family members. METHODS: This pilot study conducted a cross-sectional survey of 37 primary care physicians working at small urban and suburban clinics belonging to a practice-based research network in the south central region of Texas. RESULTS: Approximately 80% of the responding physicians reported caring for patients who have been deployed to the Afghanistan or Iraq war zones, or had a family member deployed. Although these physicians noted a variety of conditions related to physical trauma, mental illnesses and psychosocial disruptions such as marital, family, financial, and legal problems appeared to be even more prevalent among their previously deployed patients and were also noted among family members of deployed veterans. CONCLUSIONS: Community-based primary care physicians should be aware of common post-deployment health conditions and the resources that are available to meet these needs.

Accumulation of Good Intentions: How Individual Practice Guidelines Lead to Polypharmacy in the Treatment of Patients with Polytrauma.

Polytrauma clinical triad (PCT) is the comorbid occurrence of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and pain after trauma. No clinical practice guidelines for postacute care of patients with PCT currently exist; instead, clinical practice guidelines have been published for the three conditions (TBI, PTSD, and pain) as distinct clinical entities. Using multiple, individual practice guidelines for a patient with PCT may lead to unintended prescription of multiple and potentially adversely interacting medications (ie, polypharmacy). Polypharmacy, especially that which includes central nervous system-acting medications, may lead to overdose, suicidality, and chronic symptomatology. Current individual guidelines for each condition of PCT do not address how to coordinate care for the polytraumatic diagnosis. The purpose of this Practice Management piece is to describe the unintended consequences of polypharmacy in patients with PCT and to discuss mitigation approaches including rational prescribing, nonpharmacologic alternatives, and interdisciplinary coordination.

Experiential avoidance is associated with medical and mental health diagnoses in a national sample of deployed Gulf War veterans.

A substantial minority of deployed Gulf War veterans developed posttraumatic stress disorder (PTSD), depression, and several chronic illnesses. Although military combat and exposure to certain nuclear, biological, and chemical agents (NBCs) increase risk for post-deployment health problems, they do not fully explain many Gulf War veteran health diagnoses and are not viable treatment targets. Experiential avoidance (EA; one's unwillingness to remain in contact with unpleasant internal experiences) is a modifiable psychosocial risk factor associated with PTSD and depression in veterans as well as pain and gastrointestinal diseases in the general population. In this study, we recruited a national sample of deployed Gulf War veterans (N = 454) to test the hypothesis that greater EA would be significantly associated with higher lifetime odds of PTSD, depression, "Gulf War Illness" (GWI/CMI), and other chronic illnesses common in this veteran cohort. Participants completed a self-report battery assessing demographic, military-related, and health-related information. Multivariate analyses showed that after adjusting for age, sex, race, combat exposure, and NBC exposure, worse EA was associated with higher lifetime odds of PTSD, depression GWI/CMI, gastrointestinal problems, irritable bowel syndrome, arthritis, fibromyalgia, and chronic fatigue syndrome (ORs ranged 1.25 to 2.89; effect sizes ranged small to large), but not asthma or chronic obstructive pulmonary disease. Our findings suggest medical and mental health providers alike should assess for EA and potentially target EA as part of a comprehensive, biopsychosocial approach to improving Gulf War veterans' health and wellbeing. Study limitations and future research directions are also discussed.

A Family's Affair: Caring for Veterans with Penetrating Traumatic Brain Injury.

Approximately 1.1 million family members are primary caregivers to post 9/11 veterans. These military caregivers assume a role that requires a long-term commitment that may affect their own health status; however, the impact on health among military caregivers is underestimated and underrepresented. As part of a larger retrospective cohort study that aimed to assess the health-related outcomes of post 9/11 veterans with penetrating traumatic brain injury (pTBI), we examined the health impact of caregiving on caregivers. Caregivers (n = 66) of veterans with pTBI completed a survey that captured the veterans' and their own health-related outcomes. Surveys included veteran and caregiver sociodemographics, caregiver role, tasks, burden, and caregiver-reported measures of veterans' health and quality of life. The participants were spouses (58%) and parents (32%) providing full-time assistance for more than 5 yr (74%). In their caregiver role, they provided assistance with activities of daily living and emotional/social support. Forty-eight percent of these caregivers met the definition of experiencing clinically significant burden. Veterans with pTBI had other comorbidities (e.g., depression, cognitive dysfunction, and anger), which were associated with caregiver burden. The findings further confirm the impact of caregiving on health status of caregivers, specifically when assisting veterans with pTBI.

Opioid Use Patterns Among Active Duty Service Members and Civilians: 2006-2014.

Introduction: Between 2001 and 2009, opioid analgesic prescriptions in the Military Health System quadrupled to 3.8 million. The sheer quantity of opioid analgesics available sets the stage for issues related to misuse, abuse, and diversion. To address this issue, the Department of Defense implemented several directives and clinical guidelines to improve access to appropriate pain care and safe opioid prescribing. Unfortunately, little has been done to characterize changing patterns of opioid use in active duty service members (ADSM), so little is known about how combat operations and military health care policy may have influenced this significant problem. We examined changes in opioid use for ADSM between 2006 and 2014, compared trends with the civilian population, and explored the potential role of military-specific factors in changes in opioid use in the Military Health System. Materials and Methods: After obtaining Institutional Review Board approval, administrative prescription records (Pharmacy Data Transaction Records) for non-deployed ADSM were used to determine the number of opioid prescriptions dispensed each year and the proportion of ADSM who received at least one prescription per month between 2006 and 2014. Based on the observation and the literature, we identified December 2011 as the demarcation point (the optimal point to identify the downturn in opioid use) and used it to compare opioid use trends before and after. We used an autoregressive forecast model to verify changes in opioid use patterns before and after 2011. Several interrupted time series models examined whether military system-level factors were associated with changes in opioid use. Results: Between 2006 and 2014, 1,516,979 ADSM filled 7,119,945 opioid prescriptions, either in military treatment facilities or purchased through TRICARE. Both active duty and civilian populations showed signs of decreasing use after 2011, but this change was much more pronounced among ADSM. The forecast model showed a significant difference after 2011 between the projected and actual proportion of ADSM filling an opioid prescription, confirming 2011 as a point of divergence in opioid use. Interrupted time series models showed that the deflection point was associated with significant decreases. A significant increase of 0.261% in opioid prescriptions was seen for every 1,000 wounded in action service members in a given month. Troops returning from Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn did not appear to influence the rates of use. Even after accounting for returning troops from Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn and wounded in action counts, the deflection point was associated with a lower proportion of ADSM who filled an opioid prescription, leading to a decrease of 1.61% by the end of the observation period (December 2014). Conclusion: After December 2011, opioid use patterns significantly decreased in both civilian and ADSM populations, but more so in the military population. Many factors, such as numbers of those wounded in action and the structural organization of the Military Health System, may have caused the decline, although more than likely the decrease was influenced by many factors inside and outside of the military, including policy directives and cultural changes.

Mining Major Transitions of Chronic Conditions in Patients with Multiple Chronic Conditions.

OBJECTIVES: Evolution of multiple chronic conditions (MCC) follows a complex stochastic process, influenced by several factors including the inter-relationship of existing conditions, and patient-level risk factors. Nearly 20% of citizens aged 18 years and older are burdened with two or more (multiple) chronic conditions (MCC). Treatment for people living with MCC currently accounts for an estimated 66% of the Nation's healthcare costs. However, it is still not known precisely how MCC emerge and accumulate among individuals or in the general population. This study investigates major patterns of MCC transitions in a diverse population of patients and identifies the risk factors affecting the transition process. METHODS: A Latent regression Markov clustering (LRMCL) algorithm is proposed to identify major transitions of four MCC that include hypertension (HTN), depression, Post- Traumatic Stress Disorder (PTSD), and back pain. A cohort of 601,805 individuals randomly selected from the population of Iraq and Afghanistan war Veterans (IAVs) who received VA care during three or more years between 2002-2015, is used for training the proposed LRMCL algorithm. RESULTS: Two major clusters of MCC transition patterns with 78% and 22% probability of membership respectively were identified. The primary cluster demonstrated the possibility of improvement when the number of MCC is small and an increase in probability of MCC accumulation as the number of co- morbidities increased. The second cluster showed stability (no change) of MCC overtime as the major pattern. Age was the most significant risk factor associated with the most probable cluster for each IAV. CONCLUSIONS: These findings suggest that our proposed LRMCL algorithm can be used to describe and understand MCC transitions, which may ultimately allow healthcare systems to support optimal clinical decision- making. This method will be used to describe a broader range of MCC transitions in this and non-VA populations, and will add treatment information to see if models including treatments and MCC emergence can be used to support clinical decision-making in patient care.

Use of Health Care System-Supplied Aspirin by Veterans With Postoperative Heart Attack or Unstable Angina.

Evidence-based guidelines for the use of aspirin in secondary prevention of cardiovascular disease events are well established. Despite this, the prevalence of aspirin use for secondary prevention is suboptimal. The study aimed to determine the prevalence of aspirin use for secondary prevention of cardiovascular disease events when it is dispensed as a prescription, as is performed in the Veterans Affairs (VA) managed care system. VA patients who had undergone major surgery and experienced a postoperative myocardial infarction (MI) or unstable angina between the years 2005 and 2009 were identified from administrative databases. VA pharmacy records were used to determine whether a prescription for aspirin was filled after the postoperative MI or unstable angina. Multivariable logistic regression models estimated odd ratios of filling aspirin prescriptions for the predictors of interest. Of the 321,131 men and women veterans who underwent major surgery, 7,700 experienced a postoperative MI or unstable angina. Among those 7,700, 47% filled an aspirin prescription. Only 59% of veterans with no co-pay filled an aspirin prescription. Aspirin fills were more common in younger veterans, Blacks, Hispanics, males, hypertensive veterans, mentally ill patients, those with no co-pay and those prescribed antiplatelets/anticoagulants in addition to aspirin postoperatively. These findings suggest that the impact of dispensing aspirin as a prescription may not be significant in increasing the appropriate use of aspirin for secondary prevention.

Incidence of musculoskeletal and neoplastic diseases in patients on statin therapy: results of a retrospective cohort analysis.

BACKGROUND: Because of their beneficial cardiovascular effects, several studies have recently advocated starting statins at a young age for primary prevention. However, some reports suggest that statin therapy may be associated with an increased incidence of musculoskeletal and neoplastic diseases. This study was conducted to investigate the incidence of various musculoskeletal and neoplastic diseases in statin users and nonusers. METHODS: A retrospective cohort study of patients in the San Antonio Military Multi-Service Market during the period from October 1, 2003, to March 5, 2010, was conducted. The International Classification of Diseases, 9th edition, diagnosis codes between 2 cohort groups-statin users and nonusers-were compared. Statin users were those patients with at least one 3-month prescription for a statin in the fiscal year 2004. Nonusers were those patients who received a prescription-but not a statin-during the period of the study. Both groups were assessed for the development of musculoskeletal and neoplastic diseases in the following 4-year period (October 1, 2004, to September 30, 2009). RESULTS: A total of 92,360 patients were identified: 12,980 statin users and 45,997 nonusers. After adjusting for age, sex and Charlson comorbidity index, statin users had significantly higher rates of osteoarthritis and arthropathy (odds ratio: 1.26; 95% confidence interval: 1.19-1.33), and dorsopathies, rheumatism and chondropathies (odds ratio: 1.20; 95% confidence interval: 1.12-1.27). CONCLUSIONS: In this retrospective analysis, statin use was associated with an increased incidence of musculoskeletal diseases, including arthropathy. Further studies are needed to provide physicians and their patients with adequate information regarding statin therapy, particularly if recommended for primary prevention in younger populations.

Psychologic disorders and statin use: a propensity score-matched analysis.

STUDY OBJECTIVE: To evaluate the association between statin therapy and the risk of psychologic disorders including schizophrenia, psychosis, major depression, and bipolar disorder in a military population. DESIGN: Retrospective, observational, population-based, propensity score-matched, cohort study. SETTING: Database of a patient population enrolled in the San Antonio Military Multi-Market Area as Tricare Prime or Plus. PATIENTS: Medical records were reviewed from 46,249 patients aged 30-85 years who were continuously enrolled in the San Antonio Military Multi-Market Area as Tricare Prime or Plus from October 1, 2003-March 1, 2010. Data were obtained from the Military Health System Management Analysis and Reporting Tool (M2). Based on drug fills during fiscal year 2005, patients were stratified as statin users (13,626 patients received at least 90-days supply of statin) or nonusers (32,623 patients never received a statin during the study period). A propensity score-matched cohort of 6972 statin users and 6972 nonusers from this population was created. MEASUREMENTS AND MAIN RESULTS: The occurrence of psychologic disorders between October 1, 2005, and March 1, 2010, was determined using prespecified groups of ICD-9-CM, Psych1: schizophrenia, schizoaffective disorders, and other psychosis; Psych2: major depression and bipolar disorder; Psych3: all psychologic disorders as identified by the Agency for Health Research and Quality-Clinical Classifications (except for categories of childhood or developmental psychiatric disorders). Between matched pairs of statin users and nonusers, the odds ratios and 95% confidence intervals were as follows: Psych1 (0.9, 0.75-1.05), Psych2 (1.02, 0.94-1.11), and Psych3 (1.02, 0.96-1.1), respectively. CONCLUSION: The risk of developing psychologic disorders was similar in this cohort of propensity score-matched statin users and nonusers.

Intensity and duration of obesity-related counseling: association with 5-Year BMI trends among obese primary care patients.

We examined 5-year trends in BMI among obese primary care patients to determine whether obesity-related education such as nutrition counseling or a weight management program was associated with declines in BMI. Veterans with BMI ≥30 kg/m(2) and ≥1 primary care visits in fiscal year 2002 were identified from the Veterans Health Administration's (VHA) national databases. Outpatient visits from fiscal year 2002-2006 for nutrition counseling, exercise, or weight management were grouped into five categories varying in intensity and duration: (i) intense-and-sustained, (ii) intense-only, (iii) irregular, (iv) limited, and (v) no counseling. Generalized estimating equation assessed associations between obesity-related counseling and BMI trend (annual rate of BMI change fiscal year 2002-2006) among cohort members with complete race/ethnic data (N = 179,881). Multinomial logistic regression compared intensity and duration of counseling among patients whose net BMI increased or decreased by ≥10% vs. remained stable. Compared with patients receiving "intense-and-sustained" counseling, the BMI trend of those receiving "intense-only" or "irregular" counseling was not significantly different, but patients receiving "no counseling" or "limited counseling" had significantly higher rates of decreasing BMI (-0.12 and -0.08 BMI per year; P < 0.01, respectively). This was especially true for veterans in their 50-60s, compared with the oldest veterans who were most likely to lose weight. In contrast, younger veterans (18-35 years) were least likely to lose weight; their BMI tended to increase regardless of counseling intensity and duration. Enhanced efforts are needed to detect and combat increasing weight trajectories among veterans who are already obese, especially among those aged 18-35 who are at greatest risk.