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Publication Briefs
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  • Traumatic Brain Injury May Be a Potentially Novel Risk Factor for Cardiovascular Disease in Veterans
    This study sought to determine the association between TBI and subsequent cardiovascular disease (CVD) in post-9/11 era Veterans. Findings showed that post-9/11 Veterans with mild TBI, moderate to severe TBI, and penetrating TBI were more likely to develop CVD compared to Veterans without TBI. Although the risk was highest shortly after injury, TBI remained significantly associated with CVD for years after the initial injury. All TBI categories increased the risk of stroke, coronary artery disease, and peripheral artery disease. Mild and moderate to severe TBI categories were also associated with an increased risk of CVD mortality. Veterans with TBI were more likely to have a history of smoking, substance use disorder, obesity, obstructive sleep apnea, insomnia, PTSD, depression, and anxiety. Conversely, hyperlipidemia, kidney disease, hypertension, and diabetes were more common in Veterans without TBI.
    Date: September 6, 2022
  • Changes in the Association between Race and Urban Residence with COVID-19 Outcomes among Veterans
    This study examined whether key sociodemographic and clinical risk factors for COVID-19 infection and mortality changed between February 2020 and March 2021 among more than 9 million Veterans enrolled in VA healthcare. Findings showed that strongly positive associations of Black race, American Indian/Alaska Native (AI/AN) race, and urban residence with COVID-19 infection, mortality, and case fatality that were observed early in the pandemic attenuated over time. The magnitude of the association between Black (vs. White) race and COVID-19 infection or mortality declined steadily from February/March 2020 to November 2020, when it was no longer significant. The association between AI/AN (vs. White) race and COVID-19 infection declined steadily over time to a negative association in March 2021. Similarly, the association between urban vs. rural location and COVID-19 infection or mortality also declined steadily over time, shifting from a positive association in February/March 2020 to a negative association in September/October 2020 and to a non-significant association in March 2021. Throughout the study period, high comorbidity burden, younger age, Hispanic ethnicity, and obesity were consistently associated with COVID-19 infection, while high comorbidity burden, older age, Hispanic ethnicity, obesity, and male sex were consistently associated with mortality. Understanding changing patterns of risk factors could be important in informing population-based approaches to prevent infection and reduce mortality by targeting those at highest risk at any given time during the course of an evolving pandemic.
    Date: October 21, 2021
  • Veterans who Undergo Bariatric Surgery May Be at Greater Risk of Unhealthy Alcohol Use
    This study evaluated changes over time in alcohol use and unhealthy alcohol use from 2 years before to 8 years after a bariatric surgical procedure among Veterans with and without pre-operative unhealthy alcohol use. Findings showed that, among Veterans who did not have unhealthy alcohol use in the 2 years before bariatric surgery, the probability of developing unhealthy alcohol use increased significantly 3-8 years after bariatric procedures. Among Veterans with unhealthy alcohol use at baseline, the prevalence of unhealthy alcohol use after surgery was higher for patients who underwent an RYGB procedure. Clinical implications suggest that patients undergoing bariatric surgical procedures should be cautioned that drinking alcohol can escalate after bariatric surgery, even in those with no previous evidence of drinking alcohol above recommended limits.
    Date: December 21, 2020
  • Rates of Mental Health Diagnoses are Higher among Veterans with Obesity
    The objective of this study was to examine rates of mental health diagnoses among a national cohort of women and men VA primary care patients with and without obesity. Findings showed that rates of any mental health diagnosis were higher among women than men and people with versus without obesity. Depression and PTSD diagnosis rates were higher for women and men with versus without obesity. For example, there was a 25% higher PTSD diagnosis rate among men with obesity versus without. Women with obesity had higher rates of psychotic disorder diagnoses than women without obesity; this was not found for men. Substance use disorder diagnosis rates were lower for women and men with versus without obesity. Anxiety diagnosis rates were slightly lower among women with versus without obesity; this was not found for men. A sizable proportion of women (46%) and men (62%) with obesity had no mental health diagnoses. Results provide further support for the finding that many Veterans have concurrent obesity and mental health diagnoses. Integrated treatments addressing obesity and mental health could benefit patients, providers, and the healthcare system by meeting patients’ physical and mental health needs in less time than separate treatments.
    Date: January 30, 2020
  • Long-term VA Healthcare Costs Similar between Bariatric Surgery Patients and Matched Controls
    This sought to determine whether bariatric surgery is associated with differential healthcare expenditures 10 years after the procedure among Veterans with severe obesity. Findings showed that total healthcare costs increased immediately following bariatric surgery but were the same as those of Veterans who had not undergone the procedure at 10 years after surgery. Ten-year results suggest that the value of bariatric surgery is associated with improvements in health and not its potential to decrease healthcare costs.
    Date: October 30, 2019
  • Low-cost Telephone Intervention Helps Obese Veterans Reduce Weight Regain after Weight Loss Program
    This study evaluated the efficacy of a maintenance intervention compared with usual care among obese Veterans – who had lost at least 4 kg in a weight loss program – from three VA primary care clinics. Findings showed that estimated mean weight regain was statistically significantly lower in the intervention (.75 kg) than the usual care group (2.36 kg). Moreover, Veterans in the intervention group maintained their weight even though the intervention decreased in frequency, shifted from in-person to telephone delivery, and involved no intervention contact in the final 14 weeks. No adverse events attributable to the intervention were observed. Focusing on maintenance-specific skills may help people maintain much of their initial weight loss 56 weeks after participating in a weight loss program.
    Date: April 4, 2017
  • Sustained Weight Loss Advantage among Obese Veterans Receiving Specific Bariatric Surgery
    This study compared 10-year weight change between Veterans who underwent Roux-en-Y gastric bypass (RYGB) and Veterans who did not undergo surgery. It also compared 4-year weight change between RYGB patients and Veterans who underwent sleeve gastrectomy (SG) and Veterans who underwent adjustable gastric banding (AGB). Findings showed that among obese Veterans who received VA care, patients who underwent RYGB lost much more weight than matched non-surgical patients – and were able to sustain most of this weight loss in the long term. RYGB patients had lost 21% more of their baseline weight at 10 years than matched non-surgical patients. More than 70% of RYGB patients had at least 20% weight loss and approximately 40% had at least 30% weight loss at 10 years compared with 11% and 4%, respectively, for non-surgical matches. Among surgical patients, RYGB patients experienced the greatest weight loss (28%) after four years; SG patients experienced significantly less weight loss than RYGB (18%), while AGB patients lost the least weight (11%).
    Date: August 31, 2016
  • Having a Diet Option Assigned vs. Choosing a Diet Leads to Greater Weight Loss among Obese Veterans
    This randomized trial evaluated whether Veterans allowed the opportunity to choose between two diets would have greater weight loss than Veterans randomly assigned a diet. Findings showed that, contrary to popular opinion, the option of choosing a diet to follow, as opposed to being assigned a diet, did not improve weight loss among obese Veterans. At 48 weeks, the estimated mean weight loss was 5.7 kg for Veterans in the Choice group and 6.7 kg for Veterans in the Comparator group. Secondary outcomes of dietary adherence, physical activity, and weight-related quality of life were similar between groups. Given that diverse diets have proven effective for weight loss, future research might examine matching patients to their optimal diet based on other characteristics (e.g., metabolic profile, genetics) instead of their preferences.
    Date: June 16, 2015
  • Differences between Men and Women Veterans Undergoing Cardiac Catheterization in VA
    This study sought to determine whether there were gender differences in clinical characteristics and comorbidities, coronary anatomy and treatment, and procedural complications and long-term outcomes after diagnostic catheterization. Findings showed that female Veterans were younger (57 vs 63 years), with fewer traditional cardiovascular risk factors, but had more obesity, depression, and PTSD than male Veterans. Compared to male Veterans, female Veterans had lower rates of obstructive coronary artery disease (CAD) (23% vs 53%), similar or lower rates of procedural complications, and lower rates of all-cause rehospitalization. Women Veterans had lower mortality at one year, even when adjusted for age, presence of obstructive disease, and multiple comorbidities. Findings suggest that a significant portion of women Veterans treated in VA catheterization labs have chest pain not related to obstructive CAD. This may represent a complex interplay of psychological stressors and somatic disease, but further research is needed.
    Date: March 1, 2015
  • Bariatric Surgery Compared to Usual Care May Lower Mortality Rates among Obese Veterans
    This study examined long-term survival in a large multi-site cohort of obese Veterans who underwent bariatric surgery compared to matched controls. Findings showed that when compared to matched control patients who did not have the surgery, obese Veterans who underwent bariatric surgery in the VA healthcare system had lower all-cause mortality starting at 5 years and up to 14 years following the procedure. After a mean follow up of 6.9 years in the surgical group and 6.6 years in the matched control group, there were a total of 263 deaths and 1,277 deaths, respectively, at the end of the 14-year study period. Study analyses estimated 1-year, 5-year and 10-year mortality rates that were 2.4%, 6.4% and 13.8% for Veterans who underwent bariatric surgery, and 1.7%, 10.4% and 23.9% for Veterans who did not undergo bariatric surgery. There were no significant differences in the association of bariatric surgery on mortality found across groups defined by sex, diabetes diagnosis, period of surgery, or super- obesity. These study results provide further evidence for the beneficial association between surgery and survival that has been demonstrated in younger, predominantly female, non-VA populations.
    Date: January 6, 2015
  • Compared to Thiazolidinediones, Sulfonylureas May Be More Likely to Cause Death and Hospitalization for Veterans with Diabetes
    This study compared long-term outcomes of the two most commonly used second-line oral hypoglycemic medications in the VA healthcare system – sulfonylureas (SUs) and thiazolidinediones (TZDs). Findings showed that Veterans with diabetes who started on SUs compared to TZDs as a second-line agent after metformin were significantly more likely to die or have an ambulatory care sensitive condition hospitalization. Patients in this study were elderly (mean age 69), primarily white (88%), and had high rates of cardiovascular comorbidities (e.g., chronic pulmonary disease, hypertension), and obesity (41%).
    Date: December 1, 2014
  • Study Compares VA Weight Loss Interventions for Veterans
    The Aspiring for Lifelong Health (ASPIRE) small-changes weight loss intervention was developed to address the need for effective weight loss treatment for vulnerable populations. This randomized clinical trial evaluated the effectiveness of the ASPIRE intervention by randomly assigning obese Veterans to one of three treatment programs: 1) the ASPIRE-Group program, delivered via in-person groups; 2) the ASPIRE-Phone program, delivered to Veterans via phone; or 3) VA’s MOVE! usual care weight management program, delivered primarily in a group format. Findings showed that all three programs resulted in significant weight loss 12 months afer baseline. Though weight loss was relatively small, ASPIRE-Group resulted in twice the weight loss (-2.8 kg) compared to the other two programs (-1.4 kg each). 20-24% of participants lost 5% of their body weight, with no differences between programs. Both ASPIRE programs (Group and Phone) resulted in more than twice the level of engagement compared to the MOVE! program; ASPIRE-Phone was associated with the greatest engagement. At 12 months, Veterans in all three programs experienced a significant improvement in life satisfaction, HDL, and functional exercise capacity.
    Date: September 9, 2014
  • Cardiovascular Outcomes after Addition of Insulin Versus Sulfonylureas in Veterans with Diabetes Taking Metformin
    This study compared time to a combined outcome of acute myocardial infarction (AMI), stroke, or death among Veterans with diabetes that were initially treated with metformin, and subsequently added either insulin or sulfonylurea. Compared to those who added a sulfonylurea, Veterans who added insulin to metformin therapy had a 30% higher risk of the combined outcome of heart attack, stroke, and all-cause mortality. Although new heart attacks and strokes occurred at similar rates in both groups, mortality was higher in patients who added insulin. Although sulfonylurea use predominated as add-on therapy, there was increasing use of insulin intensification over the study years (increasing by an average of 17% per year). Reasons may include a growing prevalence of obesity and insulin resistance, emphasis on metrics such as glycemic targets, increasing comfort with newer analog insulins, and/or the benefit in microvascular outcome prevention.
    Date: June 11, 2014
  • Anxiety Disorders and Depression Associated with Risk of Future Heart Failure among Veterans
    This study sought to determine if the risk of heart failure (HF) was greater in Veterans with: 1) a diagnosis of one or more anxiety disorders but who were free of major depressive disorder (MDD); 2) MDD but free of anxiety disorders; or 3) comorbid anxiety and depressive disorders. Findings showed that in the model that corrected for age only, Veterans with anxiety disorders, MDD, or both were each about 20% more likely to develop HF compared to Veterans without these conditions. This effect remained significant after adjusting for other HF risk factors (e.g., sociodemographics, nicotine use, substance use disorders), and was even greater after adjusting for psychotropic medications. Compared to Veterans without HF, patients with HF were significantly older and more frequently male, non-white, unmarried, holders of supplemental insurance, and were significantly more likely to have diagnoses of hypertension, diabetes, and obesity. Veterans with both anxiety and MDD were more likely to have a diagnosis of substance abuse or dependence and history of nicotine use – and to receive a prescription for psychotropic medication.
    Date: February 1, 2014
  • Factors Associated with Use of VA MOVE! Program for Obese and Overweight Veterans
    This study sought to describe facility-level variability in the utilization of MOVE! (defined as 1 or more visits) – and to examine patient- and facility-level correlates of program use. Findings showed that although substantial variation exists across VA facilities in MOVE! utilization rates (0.05% to 16%), Veterans most in need of obesity management services were more likely to access the weight management program, although at a low level. Among the 2 million VA patients meeting criteria for obesity in 2010, 4.4% had at least one MOVE! visit. Among Veterans younger than 70, to whom the program is targeted, 6% had at least one visit. Veterans were more likely to have at least one MOVE! visit if they had a higher BMI, were female, unmarried, younger, a minority, or had a psychiatric or obesity-related comorbidity. Veterans at facilities with a higher proportion of Veterans with home instability and lower obeseogenic drug prescription rates were more likely to access MOVE!.
    Date: December 10, 2013
  • Literature Review Compares Bariatric Surgery to Non-Surgical Interventions among Non-Morbidly Obese Patients with Diabetes
    Given the lack of consistency, as well as uncertainties regarding the comparative effectiveness of different procedures for bariatric surgery, investigators conducted a systematic review of the relative risks and benefits associated with surgical and non-surgical therapies for treating diabetes or impaired glucose tolerance in patients with a BMI of less than 35. Findings showed that, for patients with diabetes and a BMI of 30 to 35, current evidence suggests that bariatric surgery is associated with greater short-term weight loss and improvements in HbA1c, fasting blood glucose levels, blood pressure, and hyperlipidemia than non-surgical interventions such as medication, diet, and behavioral changes. However, the evidence was insufficient to reach definitive conclusions about long-term outcomes.
    Date: June 5, 2013
  • Gastric Bypass Surgery among Veterans Not Associated with Reduced Healthcare Expenditures Three Years Later
    Gastric bypass surgery does not appear to be associated with reduced healthcare expenditures three years after the procedure. Total expenditures trended higher for bariatric surgical cases in the year leading up to the procedure and then converged back to the lower expenditure levels of non-surgical controls one year after the procedure. Health expenditures were similar two and three years before the surgical procedure because surgical patients and non-surgical controls had similar weight and healthcare use trajectories several years before giving serious consideration to bariatric surgery. These results are notable because they contrast with results from several prior observational studies that found costs among post-surgical cases to be lower than those of non-surgical controls two to four years after the procedures. This may be explained by important differences in the populations examined (e.g., Veterans are generally older and sicker than the general population) and the methods of analysis.
    Date: July 1, 2012
  • MOVE! Weight Management Program Characteristics Associated with Patient Retention
    MOVE! program coordinators identified characteristics associated with patient retention, such as: provider knowledge of and referral to the program, reputation of the program within the medical facility, group meeting schedule (e.g. offering multiple meeting times), inclusion of physical activity in group meetings, and involvement by the MOVE! physician champion. There were no differences in patient retention in regard to the use of introductory sessions, frequency of group meetings, and topics discussed during the meetings. Coordinators at high-retention facilities were more likely to discuss efforts to improve retention. Authors suggest that training for providers is needed to assist with referral decisions, and that program planners should consider incorporating physical activity into group meetings.
    Date: July 1, 2012
  • Gastric Bypass Surgery Generates Significant Weight Loss, Especially for Caucasian and Female Veterans
    Gastric bypass surgery yields significant weight loss for most patients in VAMCs, but is particularly effective for female and Caucasian patients. Average estimated weight loss was 76 pounds at 6 months and 109 pounds at one year. Based upon estimated individual weight trajectories, 58% of the sample had lost a significant (30% or more) amount of weight one year after surgery, and <1% lost <10% of their baseline weight at 1 year. Veterans were more likely to lose 30% or more of their baseline weight if they were female or Caucasian.
    Date: March 12, 2012
  • Veterans with Diabetes and Major Depressive Disorder at Significantly Increased Risk of Myocardial Infarction
    This study sought to determine if major depressive disorder (MDD) complicates the course of type 2 diabetes and is associated with increased risk of myocardial infarction (MI) and mortality. Findings showed that Veterans with comorbid MDD and type 2 diabetes were 82% more likely to experience a MI compared to Veterans without MDD and type 2 diabetes. Veterans with MDD alone were 29% more likely to have a MI, and Veterans with type 2 diabetes alone were at 33% increased risk of MI. The incidence of MI increased in a step-wise fashion, from unaffected Veterans (2.6% incidence of MI) to those with depression only (3.5%) to those with diabetes only (5.9%) to Veterans with both conditions (7.4%). Veterans with PTSD, anxiety, and panic disorder were more likely to have a MI, as were Veterans with hypertension, hyperlipidemia, obesity, and nicotine dependence.
    Date: August 1, 2011
  • Bariatric Surgery Does Not Decrease Mortality among Obese Veterans
    This study sought to determine whether bariatric surgery is associated with reduced mortality among Veterans, who are older and predominantly male compared to prior studies. Findings showed that in a matched cohort of obese, high-risk, predominantly male Veterans (847 who underwent surgery and 847 non-surgical controls), bariatric surgery was not significantly associated with a survival benefit during a median of 6.7 years of follow-up. In unmatched comparisons of 850 Veterans who underwent bariatric surgery and 41,244 Veterans who did not, those in the surgical group were significantly younger, had higher BMIs, and had greater comorbidity burden. Surgical patients also were more likely to be super-obese. However, analyses after matching reduced the significant differences in characteristics between surgical and control patients. These analyses also controlled more closely for time of follow-up and showed that the protection conferred by surgery was small and not statistically significant after 6.7 years.
    Date: June 15, 2011
  • History of Depression Remains a Risk Factor for Heart Disease after Accounting for Other Contributing Factors among Twin Veterans
    A history of depression remained a risk factor for incident heart disease even after adjusting for numerous covariates including: sociodemographics, co-occurring psychopathology, smoking, obesity, diabetes, hypertension, and social isolation. Moreover, twins with both high genetic and phenotypic expression of depression were at greatest risk of ischemic heart disease (IHD). Results also show that twins with hypertension and twins with diabetes were more likely to have IHD, as were twins who reported no social support. Age, race, education, and marital status were not associated with IHD status.
    Date: May 1, 2010
  • Obese and Overweight Patients Receive Equal or Better Care than Patients of Normal Weight
    Among Medicare and VA patients, there was no evidence across eight quality performance measures that obese and overweight patients received worse care than normal weight patients. In fact, obese and overweight patients received marginally better care on certain measures.
    Date: April 7, 2010
  • VA Care for Obese Veterans
    Of those Veterans identified as obese, only 27.7% had an obesity diagnosis in FY02; by 2006, 53.5% had an obesity diagnosis. Although suboptimal, these rates are comparable or better than those recently reported in the public sector. Results also show that an obesity diagnosis, and not BMI per se, was the strongest predictor of receiving obesity-related education. Only about 10-13% of obese Veterans received individual or group outpatient education in nutrition, exercise, or weight management on an annual basis, and only about one-third received any obesity-related education over the five-year study period. Obese Veterans who were older than 65 years, prescribed fewer types of medications, or lacking an EMR diagnosis of obesity or diabetes were less likely to have outpatient obesity-related education. Investigators also found limited utilization of weight loss medications and bariatric surgery, which may be partially due to system barriers such as access to surgery and medications.
    Date: February 24, 2010
  • Comparing Two Weight Loss Therapies in Overweight/Obese Veterans
    This study compared a low-carbohydrate, ketogenic diet (LCKD) to orlistat combined with a low-fat, reduced-calorie diet (O+LFD). Findings show that a low-carbohydrate diet led to similar improvements as O+LFD for weight, serum lipid, and glycemic parameters – and was more effective for lowering blood pressure. While weight loss was significant and similar for both diet interventions, and decrease in waist circumference also was similar, the LCKD had a more beneficial impact than the O+LFD on systolic (-5.9 vs. 1.5 mm Hg) and diastolic (-4.5vs. 0.4 mm Hg) blood pressure. Study results also show that participants who attended 80% or more of the group counseling sessions lost considerably more weight, regardless of treatment assignment. The authors suggest that efforts be made to incorporate similarly intensive weight loss programs into medical practice.
    Date: January 25, 2010
  • “Super- obesity” Associated with Risk of Death Among Veterans Following Bariatric Surgery
    This retrospective study of 856 bariatric surgical cases conducted in 12 VAMCs between 2000 and 2006 sought to define the risk of death among Veterans with a body mass index (BMI) of 40 or greater – and to identify patient-level factors associated with mortality. Findings show that Veterans classified as “super-obese” (BMI of 50 or higher) and those with a higher chronic disease burden appear more likely to die within one year of having bariatric surgery. Authors recommend that the risks of bariatric surgery in patients with significant comorbidities should be carefully weighed against potential benefits in older male Veterans and those with super- obesity.
    Date: October 1, 2009
  • Mental Health Diagnoses Associated with Cardiovascular Risk Factors among OEF/OIF Veterans
    Studies of Veterans from prior wars found that those with PTSD are at increased risk of developing and dying from cardiovascular disease, but this risk had not yet been evaluated in OEF/OIF Veterans. This article discusses findings from a study on the association between mental health disorders, including PTSD, and cardiovascular risk factors. Findings show that OEF/OIF Veterans (male and female) with mental health diagnoses had a significantly higher prevalence of cardiovascular risk factors (e.g., hypertension, obesity, diabetes, tobacco use). The association between mental health diagnoses and cardiovascular risk factors remained after adjusting for demographics and military factors. The most common mental health diagnosis was PTSD (24%). The majority of Veterans with PTSD had comorbid mental health diagnoses: depression (53%), anxiety disorder (29%), adjustment disorder (26%), alcohol use disorder (22%), substance use disorder (10%), as well as other psychiatric diagnoses (33%).
    Date: August 5, 2009
  • Financial Incentives to Reduce Weight among Obese and Overweight Veterans
    Veterans participating in two weight loss strategies based on financial incentives lost significantly more weight than veterans in the control group. Incentive participants weighed significantly less at seven months than at the study start compared to veterans participating in the control group.
    Date: December 10, 2008

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