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- More than 80 percent of VA patients are overweight – a risk factor that contributes to cardiovascular disease, diabetes, and mortality.
- While lifestyle interventions are helpful, additional strategies are needed to help Veterans achieve sustainable health behavior changes.
- The authors share findings from a pilot study of a brief, virtual, dyadic intervention among Veterans and a support person designed to enhance support for health behavior change and weight loss.
More than 80 percent of VA patients have a body mass index (BMI) >25, which contributes to cardiovascular disease, diabetes, and mortality. Since 2006, VA has offered the MOVE! Weight Management Program, an evidence-based comprehensive lifestyle intervention targeting clinically meaningful weight loss of at least 5 percent, delivered in individual or group formats through in-person or virtual modalities. MOVE! assists Veterans in engaging in healthy eating, being physically active, and developing behavior change skills – like setting goals and monitoring progress –to support even small weight losses. Although lifestyle interventions like MOVE! are effective in the short-term for achieving clinically meaningful weight loss among individuals who participate regularly over several months, few achieve this level of engagement and most regain weight within five years.1 Therefore, we need additional strategies to help patients make sustainable health behavior changes.
Evidence indicates that a person’s health behaviors, such as eating habits, engaging in physical activity, consuming alcohol, and smoking, are strongly linked to the behaviors of their partners, family, friends, and coworkers.2 Furthermore, changes in the health behaviors of one person increase the chances that someone close to them will also adopt those new behaviors, whether healthy or unhealthy. Participation in behavioral weight loss treatment can prompt these kinds of ripple effects, with research showing untreated spouses of participants experience improvements in eating behaviors, physical activity, and weight despite not receiving the same treatment. Together, this evidence suggests that to be optimally effective, interventions aiming to modify health behaviors should address change not just in the individual, but also leverage close social contacts to support those changes. However, few behavioral weight loss interventions focus on the communities or close social relationships of the person trying to change their health behaviors and lose weight.
Interventions that intentionally include a support person (e.g., spouse/partner, family, friend) may be one way to leverage social relationships to facilitate and sustain behaviors related to weight loss more effectively. Although evidence suggests this approach may be effective for chronic disease self-management, few studies have investigated dyadic interventions for weight management.3 Two ways in which dyadic interventions can be especially helpful are: 1) capitalizing on (and making explicit) beneficial support behaviors; and 2) intervening on unhelpful behaviors enacted by close others. Addressing unhelpful behaviors, like control, criticism, or enabling, is necessary, because these behaviors can imperil attempts at health changes. Additionally, helpful and harmful behaviors are both often found within the same relationship. Dyadic approaches therefore need to not only provide weight management education to participants and their supporters, but also provide tools to enhance communication and collaboration to meet the specific support needs of the dyad.
Approaches that simultaneously address health behaviors and social relationships are consistent with VA’s Whole Health approach to Veteran care. Indeed, relationships are a core component of Whole Health’s Circle of Health, yet dyadic or family interventions for weight management are not yet a standard component of VA’s offerings.
To address this gap, our research team developed Together2Lose (T2L), a brief, virtual, dyadic intervention among Veterans and a support person (“partner”) of their choosing to enhance support for health behavior change and weight loss. We conducted a mixed-methods pilot study to evaluate the feasibility and acceptability of T2L among Veterans and their partners. The main eligibility criteria for Veterans included a BMI>30kg/m2 or BMI>25kg/m2 and an obesity-related condition (e.g., diabetes, cardiovascular disease), an eligible and willing cohabitating partner (e.g., spouse/partner, family, friend), and access to an Internet-enabled device with a web camera. Three doctoral-level psychology trainees delivered the four structured sessions through VA Video Connect and two brief check-ins via phone to each dyad individually over an 8-week period. Session content included education on health behavior change adapted from MOVE! and training and practice in communication skills applied to making health changes. Specifically, dyads were coached on evidence-based communication strategies, drawn from partner-assisted therapies that help with effective problem-solving and self-disclosure. Each week, study clinicians led dyads through health behavior change and communication skills and assisted Veterans in setting behavioral goals and developing a support plan for those goals in collaboration with their partner.
We measured primary feasibility and acceptability outcomes qualitatively through post-intervention interviews with Veterans and partners separately, and quantitatively through measures of participant satisfaction, recruitment, and retention. Veterans participated in virtual weight checks over VA Video Connect with study staff using a study-provided scale at baseline, 8 weeks, and 16 weeks to preliminarily examine weight change as a secondary effectiveness outcome. Veterans and partners also completed web-based surveys at these timepoints, which included additional secondary effectiveness outcomes (e.g., health behaviors and social support for health behaviors).
Fifty-one Veterans who we contacted by mail opted out of the study, 35 of whom selected a reason for non-participation consistent with ineligibility (e.g., lived alone). We assessed 279 Veterans for eligibility over the phone, of whom 112 were ineligible and 155 declined. We enrolled 12 dyads in the intervention, including 8 women and 4 men. Nine dyads were romantic partners (including one same-sex couple) and three included a Veteran parent and adult child. One dyad disenrolled from the study before receiving their first intervention session; remaining dyads completed all intervention sessions and 8-week surveys and weight checks. Data collection is ongoing for 16-week outcomes.
During post-intervention qualitative interviews, both Veterans and partners expressed high satisfaction with T2L. They appreciated the flexibility of a virtual intervention and experienced few technological challenges. They found content on healthy eating and how to effectively communicate with each other regarding healthy eating most beneficial. Veterans, as well as their partners, reported changes in their health behaviors, especially healthy eating. Importantly, they described improvements in communication that helped support these changes and also applied these communication skills to other relationships. Even dyads who were perceived as having good communication at baseline identified benefits of this brief intervention. Several participants described a desire for additional tailoring of weight management education to their level of knowledge and their individual barriers to making health behavior changes, such as mental health symptoms.
Our preliminary results demonstrate that it is feasible and acceptable to integrate support persons into behavior change programs and interventions at VA. Remote delivery of such programs may reduce some barriers to participation and enhance feasibility of dyadic interventions, addressing a common concern with dyadic approaches. Although efficacy trials are needed, even brief interventions like T2L may effectively incorporate support persons to help facilitate and sustain behavior change among Veterans, as well as their loved ones. Similar strategies could be considered for other health conditions necessitating difficult and long-lasting lifestyle changes, such as cardiovascular disease, diabetes, chronic pain, and mental health conditions. Our team is pursuing opportunities to extend this work to developing and evaluating dyadic interventions for other conditions affecting the health and well-being of Veterans in service of a Whole Health approach to Veteran-centered care.
- Maciejewski ML, Shepherd-Banigan M, Raffa SD, Weiden-bacher HJ. “Systematic Review of Behavioral Weight Management Program MOVE! for Veterans,” American Journal of Preventive Medicine 2018; 54(5):7014-714.
- Smith KP, Christakis NA. “Social Networks and Health,” Annual Review of Sociology 2008; 34:405-18.
- Martire LM, Helgeson VS. “Close Relationships and the Management of Chronic Illness: Associations and Interventions,” American Psychologist 2017; 72(6):601-12.