obesity in the veteran population a growing problem jimmy hall, rn, msn

Obesity in the Veteran

PopulationA Growing Problem

Jimmy Hall, RN, MSN

Objectives

• Define Overweight/Obesity• Recognize complications• Identify who is at risk• Identify areas of prevention• Distinguish methods of treatment

Defined• Overweight and obesity are both labels for ranges

of weight that are greater than what is generally considered healthy for a given height.

• The terms also identify ranges of weight that have been shown to increase the likelihood of certain diseases and other health problems.

Overweight and Obesity. (2010). Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/obesity/defining.html

Overweight vs. Obese• Overweight - Adults with a body mass index (BMI),

calculated as weight in kilograms divided by height in meters squared, between 25 and 30 are considered overweight.

• Obese - Adults with a BMI greater than or equal to 30 are considered obese.

• Morbidly Obese - Anyone who is more than 100 pounds overweight or who has a BMI greater than or equal to 40.

Obesity. (2010). National Center for Biotechnology Information.

Obesity

• BMI is calculated from a person's weight and height and provides a reasonable indicator of body fatness and weight categories that may lead to health problems.

• In 2009, only Colorado and the District of Columbia had a prevalence of obesity less than 20%.

• Thirty-three states had a prevalence equal to or greater than 25%.– Nine of these states (Alabama, Arkansas, Kentucky, Louisiana,

Mississippi, Missouri, Oklahoma, Tennessee, and West Virginia) had a prevalence of obesity equal to or greater than 30%!!

Overweight and Obesity. (2010). Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/obesity/data/trends.html

Body Mass Index (BMI)

• Body Mass Index (BMI) is a number calculated from a person's weight and height.

• Some people question the validity of BMI itself as an indicator of obesity.– BMI is higher in higher in

highly physically fit individuals, such as professional athletes

Percent of Obese (BMI > 30) in U.S. Adults

Overweight and Obesity. (2010). Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/obesity/data/trends.html

What Causes It?

• Increased Food Intake• Increased Alcohol Consumption• Sedentary Lifestyle• Genetics – children of obese parents are 10 times more likely to be

obese than children with parents of normal weight

• Antidepressants/Antipsychotics• Hypothyroidism (5-10 pound gain)


Complications High blood pressure (hypertension ) High blood cholesterol (dyslipidemia ) Type 2 (non-insulin dependent) diabetes Coronary heart disease Angina pectoris Congestive heart failure Stroke Gallstones Cholescystitis and cholelithiasis Gout Osteoarthritis Obstructive sleep apnea Some types of cancer (such as

endometrial, breast, prostate, and colon) Complications of pregnancy such as;

gestational diabetes, gestational

hypertension and preeclampsia as well as complications in operative delivery (i.e., c-sections).

Poor female reproductive health (such as menstrual irregularities, infertility, irregular ovulation)

Bladder control problems (such as stress incontinence)

Uric acid nephrolithiasis Psychological disorders (such as

depression, eating disorders, distorted body image, and low self-esteem)

Health Impact. (2006). Department of Veterans Affairs. Retrieved from http://www.move.va.gov/whyMove_health.asp

Who is at Risk?

• People who are at higher risk for obesity include:– Lower income groups– Former smokers– People with chronic mental illness– People with disabilities– People with a sedentary lifestyle


Who Else Is At Risk?

Veterans!

How Is This Possible?

• New recruits must pass medical evaluation to enter military service, which would screen out those with serious pre-existing obesity or obesity-related chronic conditions.

• Physical fitness is mandated throughout a military career, and some evidence suggests that higher exercise levels are maintained after discharge from service.

• Tobacco smoking has also been found to be more common among Veterans than among non-Veterans – which might limit weight gain.

Koepsell, T., Littman, A., & Forsberg, C. (2011). Obesity, overweight, and their life course trajectories in veterans and non-veterans. Obesity. Advance online publication.

Veterans Receiving Care at VA

“Veterans who received health care from the VA had higher rates of obesity than the general population, with significant levels of associated comorbid disease and disability, and low rates of preventive health behaviors.”

“The results of the current study show a substantial health burden from obesity among Veterans cared for by the VA.”

Nelson, K. (2006). The burden of obesity among a national probability sample of veterans. Journal of General Internal Medicine. 21(9):915-9.

Recent Study National Health and Nutrition Examination

Survey (NHANES)– Examined data from 1999 – 2008– Looked at individuals aged 30 years or older

• 21,974 non-Veterans• 3,768 Veterans

– Height, weight, and waist circumference were assessed by direct measurement in all years, and self-reported height and weight were also obtained in all years

– Age of leaving military not known– Rate of increase in BMI since age 25 years was significantly higher for

Veterans aged 30 – 44 years compared to same age non-Veterans.


Waist Circumference

• Fat stored around the middle of the body (the waist or abdomen) can put you at risk for:o High Blood Pressureo High Blood Cholesterolo Type-2 Diabeteso Heart Diseaseo Stroke

• This risk increases with a waist sizeo 35 inches or greater for womeno 40 inches or greater for men.

MOVE! Q&A. (2010). US Department of Veterans Affairs. Retrieved from http://www.move.va.gov/QandA.asp#MOVE!

Did You Know?

Studies have shown that extra weight around the waistline is more dangerous to the heart than extra weight that is on the hips and thighs.


Veteran Weight(%)


BMI Greater than 25

BMI Less than 25

24.6%

75.4%


Non-Veteran Weight (%)


BMI Greater than 25BMI Less than 25

34.6%65.4%


Veteran Weight (%)

Waist Circumference

Waist-Stature Ratio

Percent Body Fat

0 5 10 15 20 25 30 35

13.9

14.1

18.4

30.8

31.5

30.3

31.1

31.2

30.6

24.3

23.3

20.6Highest

High

Low

Lowest


Veteran and Non-Veteran ComparisonAbove Average Weight (%)

Waist Circumference Waist-Stature Ratio Percent Body Fat0

10

20

30

40

50

60

70

80

90

55.4% 54.5%

81.5%

52.3% 52.8%

79.8%

Veteran

Non-Veteran


Study #2• VA Statistical Information– Cross-sectional analysis of 1,803, 323 veterans

receiving outpatient care at 136 VA medical facilities in 2000

– BMI calculated with data broken into groups based on gender and examined by age and race/ethnicity

– Of 93,290 women American Veterans receiving care, 68.4% were at least overweight, with 37.4% classified as obese.

– Of 1,710,032 men, 73.0% were at least overweight, with 32.9% being obese.

Das, S., Kinsinger, L., Yancy, W., Wang, A., Ciesco, E., Burdick, M., & Yevich, S. (2005). Obesity prevalence among veterans at veterans affairs medical facilities. American Journal of Preventive Medicine: 28(3), 291 – 294.

Male vs. Female Veteran Weight

Overweight Normal/Underweight

73.0%

27.0%

68.4%

31.6%

Overweight vs. Normal/Underweight

Male Female


Male vs. Female Veteran Weight

Overweight Obese0

5

10

15

20

25

30

35

40

4540.1%

32.9%31.0%

37.4%

Male

Female


Female Veteran BMI (%) by Race

Overweight (BMI 25 - 29)

Class I Obese (BMI 30 - 34.9)

Class II Obese (BMI 35 - 39.9)

Class III Obese (BMI ≥ 40)

0

5

10

15

20

25

30

35

40

45

29.1

22.4

11.1

7.2

34.4

22.2

8.9

3.7

30.8

19.5

8.9

5.1

39.1

18.3

7.5

3.2

23.6

9.1

2.6 1.1

34.1

18

6.8

3.1

Native Americans

African Americans

White

Hispanic

Asian American

Unknown


Male Veteran BMI (%) by Race

Overweight (BMI 25 - 29.9)

Class I Obese (BMI 30 - 34.9)

Class II Obese (BMI 35 - 39.9)

Class III Obese (BMI ≥ 40)

0

5

10

15

20

25

30

35

40

45 38.8

23.4

8.2

3.5

36.3

20.3

6.8

3

38.9

22.3

7.8

3.5

42.8

21.4

6.2

2.3

38.2

13.7

4.8 2.1

42

22.7

7

2.7

Native Americans

African Americans

White

Hispanics

Asian Americans

Unknown


We Know There’s a Problem…Now What?

Prevention

“Many diseases can be prevented, yet health care systems do not make the best use of their available resources to support this process. All too often, health care workers fail to seize patient interactions as opportunities to inform patients about health promotion and disease prevention strategies.”

Integrating prevention into healthcare. (2011). World Health Organization. Retrieved from http://www.who.int/mediacentre/factsheets/fs172/en/

Primary Prevention

• Primary prevention is the prevention of a disease before it occurs.

• Given that many conditions are preventable, every health care interaction should include prevention support.– When patients are provided with information and skills to

reduce health risks, they are more likely to eat healthy foods and to engage in physical activity.


• A collaborative management approach at the primary health care level with patients, their families and other health care actors is a must to effectively prevent many major contributors to the burden of disease.

Make prevention an element of every health care interaction!!


Primary Prevention

What If Prevention Is Not An Option?

Treatment

• Types of Treatment:– Exercise– Diet– Weight Loss Medications– Surgery• Gastric Bypass• Laparoscopic Gastric Banding


Exercise• Adults need at least:

2 Hours and 30 Minutes (150 minutes) of moderate-intensity aerobic activity (i.e. brisk walking) every week

AND Muscle-strengthening activities on

2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).

How much physical activity do adults need? (2011). Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html

Barriers for Exercising

1. Lack of Interest2. Shortness of Breath3. Joint Pain4. Perceived Lack of Fitness5. Lack of Energy6. Doubt that Exercise Can

Lengthen Life

Crombie, I., Irvine, L., Williams, B., McGinnins, A., Slane, P., Alder, E., & McMurdo, M. Why older people do not participate in leisure time physical activity: a survey of activity levels, beliefs and deterrents. Age and Ageing 2004; 33: 287–292

Diet Recommendations

• The Dietary Guidelines for Americans, 2010, released on January 31, 2011, emphasize three major goals for Americans:1. Balance calories with physical activity to manage weight 2. Consume more of certain foods and nutrients such as fruits,

vegetables, whole grains, fat-free and low-fat dairy products, and seafood

3. Consume fewer foods with sodium (salt), saturated fats, trans fats, cholesterol, added sugars, and refined grains

Dietary Guidelines for Americans, 2010. (2011). U.S. Department of Health and Human Services. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf

Weight Loss Medications• If lifestyle changes do not promote weight loss after

6 months, drugs should be considered.• Many side effects related to many medications• Many drugs are constanly being pulled from market

NHLBI Obesity Education Intiative: The Practical Guide. Retrieved from http://www.move.va.gov/download/Resources/NIH_Obesity_Guidelines_Practical_Guide.pdf

Weight Loss Medications

Prescription Medications for the Treatment of Obesity. (2010). National Institutes of Health. Retrieved from http://win.niddk.nih.gov/Publications/prescription.htm#fdameds

Surgical Treatment

Laparoscopic Gastric Banding - the surgeon places a band around the upper part of your stomach, creating a small pouch to hold food. The band helps you limit how much food you eat by making you feel full after eating small amounts

Gastric Bypass - helps you lose weight by changing how your stomach and small intestine handle the food you eat. After the surgery, you will not be able to eat as much as before, and your body will not absorb all the calories and other nutrients from the food you eat.


Laparoscopic Gastric Banding

Gastric Bypass

What is the VA Doing?


• MOVE! Program– MOVE! is VA's national weight management program

for veterans.– All VA facilities have been mandated to initiate MOVE!

or an alternative weight management program.– The MOVE! Program has been designed for both men

and women.– The MOVE! Program is designed for veterans of all

ability levels.


MOVE! Success Story!

• Ernie Lohmann– Bay Pines VA Healthcare

System– After 4 years in program,

Ernie lost 225 pounds!– Discontinued all three of

his diabetes medications!– Sleep apnea has all but

disappeared!– "It’s like a whole new life."


• Weight Loss Medications

Weight Loss Medications Sibutramine

• An appetite suppress, working via norepinephrine and serotonergic mechanisms in the brain.

Orlistat (Xenical) • Orlistat is approved for the management of obesity, including:

– Weight loss and weight management when used in conjunction with a reduced-calorie diet

– Reduce the risk of weight regain after prior weight loss – Also, indicated for obese patients with an initial body mass index greater

than 30 / greater than 27 in the presence of other risk factors.

• In the gastrointestinal tract it prevents the breakdown of triglycerides into free fatty acids, thus inducing a caloric deficit by reducing systemic absorption of fat.

National PBM Drug Monograph: Orlistat Monograph. (2005). VHA Pharmacy Benefits Management Strategic Healthcare Group and the Medical Advisory Panel. Retrieved from http://www.move.va.gov/download/Resources/NationalPBMDrugMonographOrlistat.pdf

• Surgery– Weight loss surgery is not typically the first option

for weight loss. – It is available at some VA facilities for suitable

candidates.• As of July 2004, more than 800 bariatric operations

have been performed at VA medical centers.




• Pre-Bariatric Surgery Treatment and Assessment

– Patients with a body mass index (BMI) of more than 40 may be considered.

– Those having a BMI between 35 - 40 with significant co-morbid medical conditions offering the potential of improvement by surgically-induced weight loss may also be considered.

– Patients must have demonstrated prior attempts at weight loss and compliance with prior treatment regimens.• Must have enrolled in MOVE! for a period of not less than 3

months.CRITERIA AND STANDARDS FOR BARIATRIC SURGERY. (2005). VHA HANDBOOK 1102.6. Retrieved from

http://www.move.va.gov/download/Resources/BariatricSurgery/BariatricSurgeryHandbook.pdf

What is the VA Doing?• Contraindications for Bariatric Surgery

– Current tobacco smokers; patients must abstain from smoking for at least 6 weeks prior to surgery

– Patients with oxygen dependent chronic obstructive pulmonary disorder (COPD)

– Patients with active hepatitis B or cirrhosis– Patients with congestive heart failure or pulmonary hypertension

unresponsive to treatment– Patients having had multiple abdominal operations, complicated incisional

hernias, or infection resulting in a multiple, diffuse, or severe intra-abdominal infection

– Patients with major psychoses and/or any non-compliance with prescribed treatment regimens

– Patients who were active substance abusers within a period of 1-year prior to the referralCRITERIA AND STANDARDS FOR BARIATRIC SURGERY. (2005). VHA HANDBOOK 1102.6. Retrieved from

http://www.move.va.gov/download/Resources/BariatricSurgery/BariatricSurgeryHandbook.pdf

Conclusion

• Overweight/Obese individuals are a growing population.

• Many complications result from being overweight/obese.

• Veterans are more likely to be overweight when compared to non-Veterans.

• Primary prevention is crucial to prevent• Many treatment options are available (but

PREVENTION is best!)

References

• Obesity. (2010). National Center for Biotechnology Information. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004552/

• Overweight and Obesity. (2010). Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/obesity/defining.html

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004552/

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004552/

obesity in the veteran population a growing problem jimmy hall, rn, msn

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