Lifestyle Change in a Large National Healthcare System Open Access
Jackson, Sandra Louise (2014)
Background : Lifestyle change programs are recommended for weight management and chronic disease prevention. However, little is known regarding their impact in healthcare settings, where participants are patients to whom lifestyle change is recommended, rather than volunteer research subjects. The Veterans Health Administration (VA) developed MOVE! (Managing Overweight / Obesity in Veterans Everywhere), which is the largest lifestyle change program in the US. Our objectives were to examine the association between MOVE! participation and (a) diabetes incidence, (b) cardiovascular disease (CVD) incidence, and (c) diabetes management.
Methods : We used national VA databases to identify approximately 2 million patients eligible for MOVE! (obese or overweight with a weight-related health condition). Cox proportional hazards models were used to analyze incidence of (a) diabetes (based on ICD-9 codes or prescription of a diabetes medication); (b) CVD including coronary artery disease (CAD), cerebrovascular disease (CBD), peripheral vascular disease (PVD), and heart failure (HF); and (c) diabetes complications (eye disease and renal disease) and medication intensification.
Results: Patients were approximately 92% male, 76% white, with mean age 52 years and BMI 32. MOVE! participants had modest weight loss over 3 years, while non-participants gained weight. Adjusting for age, race, sex, BMI, and baseline comorbidity, MOVE! participation was associated with lower incidence of diabetes: HR 0.67 (95% CI 0.61-0.74) for "intense and sustained" participants (who engaged in >8 sessions over >129 days) vs. non-participants, and HR 0.80 (0.77-0.83) for less active participants. Any amount of MOVE! participation was also associated with lower incidence of total CVD (hazard ratio 0.83, 95% CI 0.80-0.86), CAD (HR 0.81, 0.77-0.86), CBD (HR 0.87, 0.82-0.92), PVD (HR 0.89, 0.84-0.94) and HF (HR 0.78, 0.74-0.82). Among patients with diabetes at baseline, any MOVE! participation was associated with improved glycemic control despite lower medication intensification (HR 0.81, 0.79-0.83), as well as lower incidence of diabetic eye disease (HR 0.80, 0.76-0.85) and renal disease (HR 0.90, 0.86-0.93).
Conclusions : This study of the VA's MOVE! program provides evidence that participation in a large-scale, healthcare system-based lifestyle change program is associated with lower incidence of diabetes and cardiovascular disease, as well as improved diabetes management.
Table of Contents
Chapter 1: Introduction 1
Chapter 2: Literature Review 10
Epidemiology of Overweight and Obesity 10
Epidemiology of Diabetes 12
Epidemiology of CVD 15
Obesity, Diabetes, and CVD in the VA 16
Pathophysiology of Obesity's Contributions to Diabetes and CVD 19
Lifestyle Change Programs 21
The VA's MOVE! Program 27
Chapter 3: Methods 50
National VA data 50
VINCI environment 52
Defining outcomes of interest 53
Construction of complex covariates 55
MOVE! participation 57
Statistical analyses 58
Chapter 4: Weight Loss and Diabetes Incidence with the VA Lifestyle Change Program 62
Chapter 5: Reduced Cardiovascular Disease Associated with Participation in a National VA Lifestyle Change Program 94
Chapter 6: Participation in a National VA Lifestyle Change Program is Associated with Improved Diabetes Management 127
Chapter 7: Summary and Conclusions 164
Summary of Findings 164
About this Dissertation
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