Iraq and Afghanistan Veterans with PTSD Participate Less in VA s Weight Loss Program than Those without PTSD

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1 Iraq and Afghanistan Veterans with PTSD Participate Less in VA s Weight Loss Program than Those without PTSD Shira Maguen, PhD, Katherine D. Hoerster, PhD, MPH, Alyson J. Littman, PhD, Elizabeth A. Klingaman, PhD, Gina Evans-Hudnall, PhD, Rob Holleman, MPH, H. Myra Kim ScD, David E. Goodrich EdD

2 Acknowlegements This report was funded by VA Health Services Research and Development Quality Enhancement Research Initiative (QUERI) programs for Diabetes and Mental Health as part of a locally initiated quality improvement project (QLP ) Dr. Littman s time was supported in part through a VA Rehabilitation Research & Development Career Development Award (#6982) Dr. Klingaman s time was supported by the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment Dr. Evans-Hudnall s time was supported by a VA Rehabilitation Research & Development Career Development Award (1IK2RX ) No conflicts to declare

4 Background 75% of Iraq and Afghanistan Veterans enrolled in Veterans Health Administration (VHA) care are overweight or obese Iraq and Afghanistan Veterans with mental health problems may be at particularly high risk of overweight/obesity The VHA MOVE! weight management program can mitigate the risks of obesity-related morbidity Maguen et al., 2013; Kahwati et al., 2011

5 Barriers to MOVE! Participation Barriers to accessing VHA services may affect MOVE! participation especially among those with PTSD and/or depression Nearly 58% of Iraq and Afghanistan Veterans have a comorbid mental health diagnosis 48% PTSD and/or depression Maguen et al., 2013; Rosenberger et al., 2011

6 Goal Examine the relationship between MOVE! participation, mental health diagnosis, and other health and demographic variables in Iraq and Afghanistan Veterans

7 Methods VHA mental health evaluation study Retrospective, longitudinal analysis of VHA patient care databases, National Patient Care Database of MOVE! encounters Corporate Data Warehouse OEF/OIF/OND Roster ANOVA, chi-square tests, logistic regression

8 Measures Goal: Examine the relationship between MOVE! participation and mental health diagnosis in Iraq and Afghanistan Veterans Outcome: Attending desirable dose of MOVE! visits (12+ sessions in 12 months following first visit) Independent variable: Mental health diagnosis A) PTSD B) Depression but no PTSD C) Other mental health conditions (but No PTSD or depression) D) No mental health diagnosis

9 Covariates Demographics (age, sex, race, marital status) Physical health and behavioral variables (baseline weight, smoking status, disability status, medical comorbidities, pain diagnoses) Other mental health variables (psychotropic medications, number of mental health visits in last year) Medical obesity-related comorbidities and pain diagnoses derived from ICD-9-CM codes

10 Participants Veterans who attended at least one MOVE! session and had 1 weight measurement Met MOVE! eligibility criteria of: BMI 30 kg/m² or kg/m² with 1 obesityrelated comorbidity MOVE! database included 358,647 veterans of all eras; 39,584 excluded because did not meet MOVE! BMI criteria Veterans who served in Afghanistan (OEF) and Iraq (OIF/OND) Total eligible N=24,899, 12.4% of all era Veterans attending MOVE! Kahwati et al., 2011

11 Demographics Race N = 24,899 Age: Mean 38 (SD=10) Gender: 79% male, 21% female Age % Native Hawaiian/ Pacific Islander 1% American Indian/ Alaskan Native 1% Other/Missing 14% Black 23% % % % Caucasian 60%

12 Results Mental Health Diagnosis Number of MOVE! Visits Attended 8-11 visits 6% 12+ visits 4% No MH 29% Other MH 10% Depression 15% PTSD 46% 3-7 visits 21% 2 visits 15% 1 visit 54%

13 Demographic, health, and healthcare characteristics for OEF/OIF veterans with <12 vs. 12+ MOVE! visits Variables % <12 Visits N=23,907 % 12+ Visits N=992 Age category** Male ** Race * American Indian/Alaskan Native Black Native Hawaiian/Pacific Islander White Other/Missing Married Note: ** p<.001; * p<.01

14 Demographic, health, and healthcare characteristics for OEF/OIF veterans with <12 versus 12+ MOVE! visits Variable % <12 Visits N=23,907 % 12+ Visits N=992 Baseline Weight (lbs.), mean (SD)** (43.5) (46.3) # Comorbidities, mean (SD)** 1.9 (1.3) 2.3 (1.5) Current Smoker Service Connection Percent ** No Service Connection Any Pain Condition Psychotropic Prescription ** Number of Mental Health Visits in prior year ** Note: ** p<.001; * p<.01

15 Predicted probability of having 12 MOVE! visits in a year Variable Bivariate Predicted Probability (95% CI) P-value Fully Adjusted Predicted Probability (95% CI) Age (ref) 1.5 ( ) 1.7 ( ) P-value ( ) ( ) ( ) < ( ) ( ) < ( ) <0.001 Gender Female (ref) 4.8 ( ) 6.0 ( ) Male 3.8 ( ) ( ) <0.001 Marital Status Not married (ref) 4.0 ( ) 4.4 ( ) Married 3.9 ( ) ( ) Baseline Weight (increase of 20 lbs) 0.2 ( ) < ( ) <0.001 Percent Service Connection (Disability) No service connection (ref) 2.7 ( ) 3.2 ( ) ( ) ( ) ( ) ( ) ( ) < ( ) 0.002

16 Predicted probability of having 12 MOVE! visits in a year Variable Bivariate Predicted Probability (95% CI) P-value Fully Adjusted Predicted Probability (95% CI) Mental Health No MH (ref) 3.5 ( ) 4.4 ( ) P-value PTSD 4.2 ( ) ( ) Depression 4.7 ( ) ( ) Other MH 3.5 ( ) ( ) # Comorbidities (increase of 1) 0.6 ( ) < ( ) <0.001 Pain No Pain (ref) 3.8 ( ) 4.7 ( ) Any pain 4.1 ( ) ( ) Psychotropic Meds No (ref) 3.6 ( ) 3.8 ( ) Yes 6.2 ( ) < ( ) Prior Yr Mental Health Visits None (ref) 3.5 ( ) 3.4 ( ) ( ) ( ) ( ) < ( ) <0.001

17 Results Those with (vs. without) a desirable dose of participation were more likely to be: Older Female Racial/ethnic minorities Have a higher baseline BMI Have a higher disability rating More comorbidities Psychotropic medication use Greater number of mental health visits

18 Adjusted Results Probabilities of a desirable does of MOVE! participation greater among those: Without PTSD Older and female Higher baseline weight More medical comorbidities No pain Any psychotropic medication use Higher disability ratings More mental health visits

19 Discussion Only 4% of OEF/OIF Veterans enrolled in MOVE! achieved a desirable dose of care PTSD symptoms in conjunction with greater physical health problems and pain could prevent participation Possible modifications to program Address mental health symptoms, barriers to weight loss and participation, and pain

20 References Kahwati LC, Lance TX, Jones KR, Kinsinger LS. RE-AIM evaluation of the Veterans Health Administration's MOVE! Weight Management Program. Transl Behav Med (4): Maguen S, Madden E, Cohen B, Bertenthal D, Neylan T, Talbot L, Grunfelt C, Seal K. The relationship between body mass index and mental health among Iraq and Afghanistan veterans. J Gen Intern Med Suppl 2:S Maguen S, Hoerster KD, Littman AJ, Klingaman EA, Evans-Hudnall G, Holleman R, Kim HM, Goodrich DE. J Affect Disorder : doi: /j.jad Rosenberger PH, Ning Y, Brandt C, Allore H, Haskell S. BMI trajectory groups in veterans of the Iraq and Afghanistan wars. Prev Med :

21 Thank You! Questions? Dr. Maguen is always open to at

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