Lifestyle Change in a Large National Healthcare System Open Access

Jackson, Sandra Louise (2014)

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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

References 5

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

Summary 30

References 31

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

References 60

Chapter 4: Weight Loss and Diabetes Incidence with the VA Lifestyle Change Program 62

Abstract 63

Introduction 65

Methods 66

Results 71

Discussion 73

Acknowledgements 77

References 79

Chapter 5: Reduced Cardiovascular Disease Associated with Participation in a National VA Lifestyle Change Program 94

Abstract 95

Introduction 96

Methods 97

Results 101

Discussion 104

Acknowledgements 108

References 110

Chapter 6: Participation in a National VA Lifestyle Change Program is Associated with Improved Diabetes Management 127

Abstract 128

Introduction 130

Methods 131

Results 136

Discussion 139

Acknowledgements 144

References 146

Chapter 7: Summary and Conclusions 164

Summary of Findings 164

Limitations 166

Strengths 169

Implications 169

Summary 176

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