Obesity and Weight Control Practices in 2000 Among Veterans Using VA Facilities
Piedmont Health Services, Chapel Hill, North Carolina and Sandhills Community Care Network, Pinehurst, North Carolina; S.D., University of Texas Southwestern Medical School, Dallas, Texas; L.S.K., L.K., R.T.H., M.B.B., S.J.Y., Veterans Administration National Center for Health Promotion and Disease Prevention, Durham, North Carolina; Z.G., North Carolina State Center for Health Statistics, Department of Health and Human Services, Raleigh, North Carolina.
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3022 Croasdaile Drive, Suite 200, Durham, NC 27705. E-mail: Linda.Kinsinger@med.va.gov
Objective: To examine obesity prevalence and weight control practices among veterans who use Department of Veterans Affairs (VA) medical facilities (VA users).
Research Methods and Procedures: Data from the 2000 Behavioral Risk Factor Surveillance System, a telephone survey of 184, 450 adults, were analyzed. Outcome measures included BMI, weight control practices (the intent to manage weight, and diet and physical activity patterns), and receipt of professional weight control advice.
Results: Of VA users, 44% were overweight and 25% were obese. After controlling for demographic factors, VA users were somewhat less likely to be overweight (odds ratio, 0.86; 95% confidence interval, 0.74 to 1.00) but equally likely to be obese (odds ratio, 1.08; 95% confidence interval, 0.92 to 1.27), compared with non-VA users. Among obese VA users, 75% reported trying to lose weight, and another 17% reported trying to maintain weight. Of these, only 40% decreased both calorie and fat intake. Only 27% of obese VA users who reported increasing exercise to lose weight followed recommendations for regular and sustained physical activity. Of obese VA users, 59% were inactive or irregularly active. Only 51% of obese VA users received professional advice to lose weight. Obese VA users were more likely than obese non-VA users to report trying to lose weight, modifying diet to lose weight by decreasing both calories and fat intake, and receiving professional weight control advice.
Discussion: Interventions for weight management programs in VA facilities need to take into account the high prevalence of overweight/obesity among VA users and should emphasize effective weight control practices.
The prevalence of overweight and obesity has increased in the United States over the last 3 decades (1, 2, 3, 4). Results of the National Health and Nutrition Examination Survey reveal that the prevalence of being overweight/obese (BMI ≥ 25 kg/m2) among U.S. adults increased from 45% in 1960 to 1962 to 64% in 1999 to 2000 (3, 4). Similarly, the prevalence of obesity (BMI ≥30 kg/m2) increased from 13% in 1960 to 1962 to 31% in 1999 to 2000 (3, 4). Using self-reported height and weight values, the 2000 Behavioral Risk Factor Surveillance System (BRFSS)1 found prevalence of being overweight/obese (56%) and obese (20%) among U.S. adults (5) somewhat lower than National Health and Nutrition Examination Survey estimates, possibly due to inherent under-/overestimation of weight/height, common to non-verified self-reported data (6, 7).
With its rising prevalence and associated health problems, obesity is an increasingly important medical and public health issue. Studies have shown that obesity is related both to increased mortality, accounting for more than an estimated 300, 000 annual deaths (8) including 90, 000 deaths from cancer (9), and to increased morbidity from chronic diseases, including type 2 diabetes, hypertension, coronary artery disease, osteoarthritis, gallbladder disease, and certain cancers (9, 10, 11, 12). Obesity is also associated with impaired health-related quality of life and other psychological problems (13, 14).
Although obesity has been studied extensively in the general U.S. population through the BRFSS and other national surveys, few studies have examined obesity prevalence and weight practices in the veteran population. The addition of questions regarding military status in the 2000 BRFSS for the first time allows for this analysis among veteran respondents. A recent analysis of the 2000 BRFSS survey found that, compared with non-veterans, veterans had a higher prevalence of overweight/obesity, after adjusting for demographic variables (15). Less is known about obesity prevalence and weight practices among veterans who use Department of Veterans Affairs (VA) medical facilities. The Veterans Health Administration operates the nation's largest health care system, with >5 million active patients. Veterans who use VA facilities differ from veterans who do not use VA facilities and from the general population in that they are older, less educated, poorer, sicker, and more disabled (16, 17).
This study reports the prevalence of overweight and obesity from BRFSS data in veterans who use VA facilities (VA users) compared with the rest of the population who do not use VA facilities (non-VA users). We also examine weight practices, specifically the intent to lose weight, modifications in diet and exercise, physical activity patterns, and professional weight control advice, among obese VA users and obese non-VA users. This information will be important to the VA for planning programs to assist VA users in weight management efforts.
Research Methods and Procedures
Data from the 2000 BRFSS were analyzed for this study (18). The BRFSS is a cross-sectional, random-digit-dialed telephone survey of non-institutionalized adults ages 18 and older, conducted by the Centers for Disease Control and Prevention and state health departments. In 2000, 184, 450 interviews were conducted in the 50 states and District of Columbia. The questions about military status were: “Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?”; “Which of the following best describes your current military status? a) Currently on active duty, b) currently in reserves, or c) no longer in military service;” and “In the past 12 months, have you received some or all of your health care from VA facilities?” (19). Veterans were identified as respondents who had served on active duty, in the regular military, National Guard, or military reserve unit, but were no longer in military service. VA users were defined as veterans who had used VA facilities for some or all of their health care in the past 12 months. Non-VA users were defined as the remaining population composed of non-veterans and veterans who did not use VA facilities for their health care.
BMI was calculated from self-reported height and weight. Respondents were classified as normal if BMI was 18 to 24.9 kg/m2, overweight if BMI was 25 to 29.9 kg/m2, or obese if BMI was ≥30 kg/m2. Questions about height and weight were “About how much do you weigh without shoes?” and “About how tall are you without shoes?” (19).
Questions about weight practices included: “Are you trying to lose weight?” Those who answered no were asked, “Are you trying to maintain your current weight?” Positive responses to either question were followed with “Are you eating fewer calories or less fat to lose weight or to keep from gaining weight?” and “Are you using physical activity or exercise to lose weight or to keep from gaining weight?” All respondents were asked, “In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight?” (19).
Respondents were also asked about the type, duration, and frequency of two leisure-time physical activities in which they had participated most frequently in the past month. Responses were categorized into the following variables: level of physical activity (inactive, irregularly active, regular, not intense, and regular, intense, which we further dichotomized to inactive or irregularly active and regularly active); and regular and sustained physical activity (physical activity for 30 or more minutes, five or more times per week, regardless of intensity and no physical activity or <30 minutes of activity five or more times per week). Additional covariates in the analyses included demographic factors: gender, age (18 to 49, 50 to 64, 65 and older), and race (white vs. non-white).
Survey commands in STATA 7.0 (STATA Corporation, College Station, TX) were used to account for the complex multistage cluster sampling design of the BRFSS data. Descriptive statistics were generated to examine the relationship between VA-using status and BMI, sociodemographic variables, and weight practices. Multivariate binary or multinomial logistic regression was used to generate odds ratio (OR) estimates of the association between being an obese VA user and various weight-control practices, while controlling for demographic covariates mentioned. For dichotomous outcomes, binary logistic regression was used. For outcomes with more than two categories, multinomial logistic regression was used, with the null outcome as the comparison outcome group. The institutional review board of the Durham VA Medical Center approved the study.
Non-VA users comprised 98.2% (N = 178, 735) and VA users comprised 1.8% (N = 3391) of the respondents in the 2000 BRFSS. There were 23, 880 veterans identified, 13.1% of whom were VA users. Table 1 presents demographic and health status variables of non-VA users and VA users. VA users, compared with non-VA users, were more likely to be men, African American, and older than 50 years; to have less than some college education and annual incomes less than $35, 000; to have diabetes; to be current or former smokers; and to have had medical check-ups within the past 2 years.
Table 1. . Percentage* distribution of selected characteristics of non-VA users and VA users, BRFSS 2000
|Gender (N = 182, 126)|
| Female||47.3 (0.21)||5.9 (0.63)|
| Male||52.7 (0.21)||94.1 (0.63)|
|Race (N = 181, 009)|
| White||72.9 (0.20)||74.6 (1.40)|
| African American||9.4 (0.12)||14.0 (1.05)|
| Hispanic||13.2 (0.17)||8.6 (1.12)|
| Other||4.4 (0.10)||2.8 (0.38)|
|Age (N = 181, 049)|
| 18 to 29||22.0 (0.18)||4.2 (0.67)|
| 30 to 39||20.6 (0.16)||9.1 (0.93)|
| 40 to 49||20.1 (0.17)||14.1 (0.99)|
| 50 to 59||14.9 (0.14)||22.3 (1.25)|
| 60 to 69||10.9 (0.13)||21.2 (1.14)|
| >70||11.5 (0.13)||29.0 (1.32)|
|Education (N = 181, 720)|
| Some high school or less||13.3 (0.16)||14.4 (1.06)|
| High school diploma||30.9 (0.19)||33.5 (1.41)|
| Some college||27.3 (0.18)||31.9 (1.34)|
| College graduate||28.4 (0.18)||20.2 (1.15)|
|Household income (N = 156, 278)|
| <$15, 000||11.4 (0.15)||18.2 (1.2)|
| $15, 000 to 24, 999||18.3 (0.18)||28.3 (1.41)|
| $25, 000 to 34, 999||15.5 (0.16)||18.2 (1.16)|
| $35, 000 to 49, 999||18.7 (0.17)||17.5 (1.31)|
| >50, 000||36.1 (0.21)||17.8 (1.16)|
|Type 2 diabetes (N = 180, 142)|
| No||93.7 (0.11)||84.0 (1.02)|
| Yes (gestational diabetes excluded)||6.3 (0.11)||16.0 (1.02)|
|Smoking status (N = 181, 618)|
| Never smoked||53.9 (0.21)||28.9 (1.33)|
| Current smoker||22.1 (0.17)||27.6 (1.35)|
| Former smoker||24.0 (0.17)||43.5 (1.44)|
|Routine physician visit (N = 180, 063)|
| >2 years||16.0 (0.16)||8.0 (0.90)|
| 2 years ago or less||84.0 (0.16)||92.0 (0.90)|
|BMI (N = 174, 091)|
| Normal BMI, 18.0 to 24.9 kg/m2||42.9 (0.21)||31.3 (1.38)|
| Overweight BMI, 25.0 to 29.9 kg/m2||36.9 (0.21)||43.7 (1.46)|
| Obese, BMI ≥ 30.0 kg/m2||20.3 (0.17)||24.9 (1.22)|
Prevalence of Overweight and Obesity
Forty-four percent of VA users were overweight, and 25% were obese. Among non-VA users, 37% were overweight, and 20% were obese. VA users were less overweight than non-VA users [odds ratio, 0.86; 95% confidence interval (CI), 0.74 to 1.00] but similarly obese (OR, 1.08; 95% CI, 0.92 to 1.27) to non-VA users, after adjustment for demographic covariates. These results are shown in Table 2.
Table 2. . Unadjusted percentages* and adjusted odds ratios† comparing overweight and obesity between non-VA users and VA users, BRFSS, 2000
|Obese||20.3||24.9||1.08||0.92 to 1.27|
|Overweight||36.9||43.7||0.86||0.74 to 1.00|
|Normal Weight‡||42.9||31.3||1.00|| |
Weight Control Practices, Physical Activity, and Professional Weight Control Advice among Obese Respondents
Table 3 shows prevalence in percentages for weight practices, physical activity, and professional weight control advice for obese VA users and obese non-VA users. Among obese VA users, 75% reported trying to lose weight, and 93% reported trying to lose or maintain weight. Of these, 85% were reducing intake of calories, fat, or both, although only 40% were limiting both calorie and fat intake, and only 53% increased physical activity. Fifty-nine percent of obese VA users were inactive or irregularly active. Only 18% of obese VA users who reported trying to lose weight adhered to the recommendation of 30 minutes of physical activity five or more times per week, and only 27% of obese VA users who reported using physical activity to lose or maintain weight adhered to the recommendation. Only 51% of obese VA users reported receiving professional advice to lose weight.
Table 3. . Unadjusted rates (percentage)* and adjusted odds ratios† comparing weight control practices of obese non-VA users and obese VA users, BRFSS, 2000
|Weight control practices|
| Trying to lose weight||65.5||74.6||2.25||1.64 to 3.09|
| Trying to maintain weight||20.9||16.9||1.29||0.89 to 1.86|
| Neither‡||13.6||8.5||1.00|| |
| Modifying diet to lose or maintain weight||81.3||84.6||1.48||1.10 to 1.98|
| Not modifying diet to lose or maintain weight||18.7||15.4||1.00|| |
| Consuming fewer calories to lose or maintain weight||16.7||20.1||1.55||1.04 to 2.31|
| Consuming less fat to lose or maintain weight||30.1||24.2||1.16||0.82 to 1.65|
| Consuming fewer calories and less fat to lose or maintain weight||34.5||40.3||1.71||1.24 to 2.37|
| Neither fewer calories nor less fat consumed to lose or maintain weight‡||18.7||15.4||1.00|| |
| Using physical activity to lose or maintain weight||55.7||53.1||1.06||0.84 to 1.36|
| Not using physical activity to lose or maintain weight||44.3||46.9||1.00|| |
|Level of physical activity|
| Regularly active||36.0||40.8||1.19||0.94 to 1.50|
| Inactive or irregularly active||64.0||59.2||1.00|| |
|Regular and sustained physical activity|
| 30 minutes physical activity 5 or more times per week||16.2||17.8||0.97||0.72 to 1.30|
| No or less than 30 minutes physical activity 5 or more times per week||83.8||82.2||1.00|| |
|Professional advice on weight|
| Lose||33.5||51.2||2.06||1.64 to 2.59|
| Maintain||1.5||1.5||1.72||075 to 3.97|
| Neither or gain‡||65.0||47.3||1.00|| |
Among obese non-VA users, 66% reported trying to lose weight, and 87% reported trying to lose or maintain weight. Of these, 81% were reducing intake of calories or fat or both, 34% were limiting both calorie and fat intake, and 56% increased physical activity. Sixty-four percent of obese non-VA users were inactive or irregularly active. Only 16% adhered to the recommendation of 30 minutes of physical activity five or more times per week, and only 26% of obese non-VA users who reported using physical activity to lose or maintain weight adhered to the recommendation. Only 34% of obese non-VA users received professional advice to lose weight.
Table 3 also provides estimates of the association between being an obese VA user and various weight control practices, with adjustment for demographic covariates. Obese VA users were more likely than obese non-VA users to report trying to lose weight (OR, 2.25; 95% CI, 1.64 to 3.09) or trying to maintain weight (OR, 1.29; 95% CI, 0.89 to 1.86) compared with neither practice. Obese VA users were also more likely than obese non-VA users to report modifying diet to lose weight (OR, 1.48; 95% CI, 1.10 to 1.98); specifically, obese VA users were more likely than obese non-VA users to report consuming both fewer calories and less fat to lose or maintain weight (OR, 1.71; 95% CI, 1.24 to 2.37). Obese VA users were twice as likely to have received professional advice to lose weight (OR, 2.06; 95% CI, 1.64 to 2.59) and 1.7 times as likely to have received professional advice to maintain weight (OR, 1.72; 95% CI, 0.75 to 3.97).
Finally, among all obese respondents who reported receiving professional advice to lose weight, 80% also reported trying to lose weight. In comparison, among all obese respondents who reported receiving no professional weight loss advice, only 59% reported trying to lose weight.
This is the first national study to report the prevalence of overweight and obesity in veterans who use VA facilities based on self-reported heights and weights from BRFSS data. These findings will be useful as a baseline in monitoring trends over time, using future BFRSS surveys that include questions about veteran status. We found that unadjusted proportions of overweight and obesity in VA users (44% and 25%, respectively) were higher than those of non-VA users (37% and 20%, respectively) and than those reported for the general population (35% and 20%, respectively) in previous analyses of the 2000 BRFSS (5). The high prevalence of overweight/obesity among VA users represents a substantial burden of disease in this population.
The National Heart Lung and Blood Institute's guidelines recommend a reduced fat and calorie diet with 30 minutes or more of moderate intensity exercise for all or most days of the week (20). However, overweight and obese populations have been struggling to meet National Heart Lung and Blood Institute's guidelines. Recent analyses of the 2000 BRFSS found that 64% of obese U.S. adults were inactive or irregularly active (5). Previous research also noted that only 20% of the two-thirds of U.S. adults trying to lose weight followed the recommended strategies of decreasing calories and increasing physical activity and that only 40% of the two-thirds of U.S. adults using physical activity for weight loss followed the recommendation of 150 minutes or more of leisure time physical activity per week (21). Similarly, we found that 59% of obese VA users were inactive or irregularly active, and that among obese VA users who reported trying to lose or maintain weight, only a small proportion followed recommendations to decrease both calorie and fat intake and to engage in regular and sustained physical activity. Additionally, we found that obese VA users were more likely than obese non-VA users to report trying to lose weight and modifying their diet to do so, but they were not more likely to report increasing physical activity as a weight control strategy.
Although obese VA users were more likely to report receiving advice to lose weight from their health care providers, compared with other groups, only 51% reported such advice. This finding is similar to results from a recent study of obese persons in the general population with a routine check-up in the past year, less than one-half of whom reported receiving provider advice to lose weight (22). The study also showed an association between receiving professional weight loss advice and attempting to lose weight, an association confirmed in our analyses of obese respondents. Obese respondents who reported receiving professional weight loss advice were more likely to report trying to lose weight, compared with those who reported receiving no such advice.
The reasons for differences in intent to lose weight, diet modifications, and professional weight control advice between obese VA users and obese non-VA users deserve further exploration beyond the capabilities of our study and the BRFSS. There are aspects of VA users’ chronic illnesses, physical disabilities, and mental impairments not captured by the survey and analyses, which may account for differences in weight practices and receipt of professional weight control advice. There may also be differences in perspectives among physicians who care primarily for VA users, or there may be VA healthcare organizational differences, which may account for differences in weight counseling.
The findings for VA users are especially important for the VA. The burden of overweight and obesity among its users calls for increased focus on weight management and physical activity by VA facilities and health care providers. Dietary interventions for weight control should be strengthened because obese VA users seem more likely to focus on diet as a weight control strategy, rather than physical activity. By understanding the barriers to physical activity, physical activity interventions should be better designed to target those activities most amenable to obese VA users. Systematic support for self-management of obese patients’ healthy dietary and physical activity habits will also be essential. In addition, strong community linkages are important because workplaces and community centers should offer healthy alternatives for food choices and physical activity. About one-half of obese VA users still do not receive any counseling on weight control, and weight loss advice seems to be associated with weight loss attempt. Improvements in clinical information systems to better identify patients at risk and delivery system design changes, such as reminder systems, can be instituted to improve weight counseling for obese VA users. The U.S. Preventive Services Task Force recently recommended that clinicians screen all adults for obesity with BMI measurement and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults (23).
One framework that can systematically categorize these strategies for weight management in obese VA veterans is the Chronic Care Model, which has been effectively used to manage chronic illnesses in outpatient settings (24, 25) and can be applied to the problem of obesity (26, 27). In a comprehensive weight management program, system-level improvements, based on each of the six elements of the model, including organization of health care, delivery system design, decision support, self-management, clinical information systems, and community linkages, would be instituted and could lead to improved obesity management.
Our study is limited in several ways. First, BRFSS is a telephone survey. Individuals without telephones are likely to be of low socioeconomic status, a factor associated with obesity (28). Second, the BRFSS BMI values are based on self-reports. In validation studies of self-reported height and weight, patients tend to overestimate their height and underestimate their weight (6, 7). These limitations would lead to underestimation of BMI, which would underrepresent the magnitude of the problem. Third, physical activity was likely underestimated because the respondents reported data on only two structured leisure-time activities. Similarly, the survey did not include a detailed dietary assessment or allow for quantification of calorie and fat reduction. There is no reason to believe that self-reports of physical activity and diet would be significantly different between VA users and non-VA users.
In conclusion, VA has a unique opportunity to target a significant portion of its patient population for weight control. Data from studies in military populations show that an increasing prevalence of overweight and obesity is a growing concern among active duty personnel (29, 30); thus, the magnitude of the problem for the VA is likely only to increase. A national VA weight management program, incorporating strategies specific to obese VA users, will be important and will allow for the exploration of a comprehensive model for obesity management.
This study was supported by the Veterans Affairs National Center for Health Promotion and Disease Prevention (Durham, NC). This paper was presented as a poster at the Association of Teachers of Preventive Medicine Annual Meeting, Albuquerque, NM, March 27, 2003. The authors have no relevant financial interest in this article. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
Nonstandard abbreviations: BRFSS, Behavioral Risk Factor Surveillance System; VA, Veterans Affairs; OR, odds ratio, CI, confidence interval.