Military Veterans on the Frontlines
of Obesity


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Published in May Issue             

Three new papers on obesity recently published in the Journal in General Internal Medicine (JGIM) shed new light on the potential opportunities and pitfalls in helping our nation’s veterans combat an escalating obesity problem in their ranks.

The Department of Veterans Affairs (VA) says that of the 7.5 million veterans receiving its health benefits, more than 70 percent are overweight and 20 percent have diabetes. Additionally, the VA estimates that in 2013, more than 165,000 (or two percent) had a body mass index (BMI) of more than 40.

“Obesity is one of the most serious health issues that veterans face,” said Luke M. Funk, MD, MPH, a co-author of one of the JGIM studies and a minimally invasive and bariatric surgeon at the William S. Middleton Memorial Veterans Hospital in Wisconsin. “The only way we’re going to combat this is through a strong and coordinated multi-disciplinary team approach to obesity care.”

In March 2016, the Veterans Health Administration (VHA) held a Weight Management State of the Art conference to identify evidence gaps and develop a research agenda for population-based weight management for veterans. The conference included three workgroups: behavioral, pharmacologic and bariatric surgery.

According to the Funk, et.al. article on conference, the bariatric surgery workgroup agreed that evidence from randomized trials and large observational studies suggest bariatric surgery is superior to medical therapy for short- and intermediate-term remission of diabetes, long-term weight loss and long-term survival.

However, the group identified some gaps in evidence that need to be addressed for the VA around long-term remission of obesity-related conditions and diseases, mental health, substance abuse, healthcare costs, and the role of endoscopic weight loss options. The group said there was limited evidence on when to refer to bariatric surgery, the management of high-risk patients and the barriers to bariatric surgery that exist in the VA system. The group recommended the creation of a patient registry to study some of these issues and a workforce assessment to determine the VA’s capacity to increase bariatric surgery access. According to the paper, not all 135 VHA Surgery Programs have the infrastructure and approval to perform bariatric surgery procedures.

The VA currently offers three primary weight management interventions, which include MOVE! Weight Management Program, a behavior counseling program aimed at increasing physical activity and promoting healthy eating; weight loss medications and bariatric surgery.

Who undergoes bariatric surgery? The average VA patient:

  • male: 69%
  • 52-years-old
  • high prevalence of diabetes (45%)
  • hypertension (76%)
  • known heart disease (9%)

Of the 136,982 veterans who completed a MOVE! visit in in 2015, more than 65,000 were severely obese. According to a second paper on veterans by William Gunnar, MD, JD, “the number of bariatric surgery procedures performed by the VHA appears woefully low for the patient population.”

Potential reasons include: differing patient demographics, limited availability of services, and barriers to referral. Dr. Gunnar also writes that another reason for the low utilization of bariatric surgery, may be the “absence of a standardized plan of care grounded in evidence-based medicine and reflected in clinical decision support, care coordination agreements, and standardized metrics for assessing outcomes for successful care and treatment.”

Dr. Gunnar concludes the VA, which is the largest integrated healthcare system in the U.S., “is well positioned and resourced to provide comprehensive weight management to the beneficiary population.

In a third paper about improving weight management among veterans, David Atkins, MD, MPH, believes the VA has “a unique and pressing opportunity in the delivery of weight management interventions.” He suggests adopting a population-based approach to ensure that 65 to 70 percent of eligible patients are matched with the right weight loss treatment based on their needs.

The paper suggests that with the rise of overweight and obesity in the veteran population, “high-quality weight management will need to become as ubiquitous as primary care and will likely require effective and strategic coordination across interventions, especially in large health systems.”

The American Society for Metabolic and Bariatric Surgery (ASMBS) Military Committee supports the uniformed services and their members by providing a collaborative forum committed to improving the care of the bariatric patient within the military/Tricare system and advancing of the science of metabolic and bariatric surgery through a robust research consortium. This committee’s focus is to establish a collective within Military Treatment Facilities (MTFs), create uniform pathways among centers and have MBSAQIP participation from sites. Dr. Eric Ahnfeldt chairs the committee.