Pharmacotherapy for Weight Management in the VHA.

Weight management medications (WMM) are underutilized as an adjunct to behavioral and lifestyle interventions. In fiscal years 2014-2015, a total of approximately 2500 veterans-a mere 2% of veterans receiving care from the Veterans Health Administration (VHA)-eligible for a WMM received a prescription for one. A State of the Art Conference on Weight Management workgroup, focused on pharmacotherapy, developed evidence-based recommendations and strategies to foster the appropriate use of WMM in the VHA. The workgroup identified patient, prescriber, and health system barriers to and facilitators for prescribing WMM. Barriers included patient and provider concerns about medication safety and efficacy, limited involvement of primary care, restrictive medication criteria for use (CFU), and skepticism among providers regarding the safety and efficacy of WMM and the perception of obesity as a disease. Potential facilitators for removing barriers included patient and provider education about WMM and the health benefits of weight loss, increased engagement of primary care providers in weight management, relaxation of the CFU, and creation of a system to help patients navigate through weight management treatment options. Several research questions were framed with regard to WMM in general, and specifically to the care of obese veterans. While some of the workgroup's conclusions reflect issues specific to the VHA, many are likely to be applicable to other health organizations.

Weight Gain and Incident Diabetes Among HIV-Infected Veterans Initiating Antiretroviral Therapy Compared With Uninfected Individuals.

BACKGROUND: The health implications of weight gain after antiretroviral therapy (ART) for HIV infection are not well characterized and may differ from weight gain among uninfected individuals. We use data from the Veterans Aging Cohort Study to determine whether weight gain after ART has a similar association with incident type 2 diabetes mellitus (DM) as weight gained among HIV-uninfected (uninfected) individuals. METHODS: We explored associations of weight gain and incident diabetes (A1c ≥ 6.5%), in the Veterans Aging Cohort Study, a national observational study of HIV-infected (HIV+) individuals demographically matched 1:2 to uninfected controls. From 2000 to 2011, weight change was assessed in the year following ART initiation for HIV+ individuals and date of first available body mass index for uninfected individuals. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for baseline body mass index using Cox regression. RESULTS: HIV+ individuals had lower prevalence of DM at baseline (12% HIV+, 23% uninfected) and lower incident diabetes (5% HIV+, 11% uninfected). The association of weight gain with risk of DM was linear for HIV+ and uninfected but the slope of the association was steeper for HIV+. For each 5 pounds of weight gained, HIV+ had 14% increased risk of DM (HR, 1.14; 95% CI: 1.10 to 1.17) and uninfected individuals had 8% increased risk (HR, 1.08; 95% CI: 1.07 to 1.10) (P < 0.01 for interaction). CONCLUSIONS: Weight gained in the first year after ART initiation is associated with greater risk of DM than that among uninfected individuals. HIV+ individuals initiating ART who are not underweight should avoid substantial weight gain.