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Evidence Based Research Project Final Proposal
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PTSD AND OBESITY IN VETERANS 5 Abstract The title of this research project is “Addressing Post Traumatic Stress Disorder (PTSD) and Obesity in Veterans”. The project manager is Randi Bagley, PTA with the Veterans Healthcare Administration (VHA). The initial investigation for the subject of this research was to determine why, “Veterans who use the VA for health care have the highest rates of obesity compared with veterans who do not use the VA and nonveterans” (Nelson, 2006, p.915). The disease burden of obesity has become an enormous cost to health care here in the United States (Nelson, 2006). Research for this burden attempts to find out why the burden is greater in the VA health care system. Research indicates that, “Veterans have historically been at high risk for mental health problems, including PTSD” (Salisbury & Burker, 2011, p.3). The statistical significance of the prevalence of obesity along with the prevalence of PTSD in veterans appeared over and over in the studies. It was the correlation of these two illnesses that prompted the ensuing investigation and research. The evidence from this research will show that PTSD is strongly associated with obesity. It will further divulge that, while there are several clinical guidelines that target overweight and obesity, some of these practice guidelines do not currently incorporate PTSD as a risk factor for developing obesity. This research paper will present a format for modifying existing clinical practice guidelines to include screening methods for PTSD as a risk factor for obesity. Additionally, a plan for the introduction and implementation of a new guideline will be included. By modifying an existing tool, there is an expectation that the change will require a minimal amount of cost and resources, while incorporating the necessary patient characteristics needed to affect logical evidence based change in practice.
6. PTSD AND OBESITY IN VETERANS 6 Introduction Section A: Problem Description Background of the Problem According to numerous studies and research, obesity is becoming an insidious disease here in the US. Almond, Kahwati, Kinsinger, and Porterfield found that veterans are becoming alarmingly more obese than their non-military counter-parts (2008). In fact, there are some disturbing statistics that indicate obesity is on the rise in the veteran population (Almond, et al., 2008). The question of why veterans in particular are at greater risk for obesity is of great concern. The common variables and contributing factors to this phenomenon are the main focus of this investigation. The primary question is: Are veterans who suffer from Post Traumatic Stress Disorder (PTSD), compared with veterans who do not suffer from PTSD, at higher risk for developing obesity? Stakeholders/Change Agents In addition to discovering why veterans are at such high risk for obesity, the solution to the epidemic is of equal importance. For some time now clinicians at the Veterans Administration have developed programs to assist in reducing the rate of obesity in its patient population (Dahn, et al., 2011). Programs such as the Managing Overweight/ Obesity for Veterans Everywhere (MOVE) have proven to be a blessing for many veterans struggling with weight management (Dahn, et al., 2011). In a comprehensive study, conducted by the CDC (Littman, Boyko, McDonell, and Fihn, 2012), a large cross-section of patients across the Northwest population of the VA Medical
7. PTSD AND OBESITY IN VETERANS 7 Centers indicated that service members who have served in Iraq or Afghanistan wars (ages 40 – 64) were most likely to seek weight management programs (Littman, et al., 2012). This age group is more likely to feel that they have control over their health and health related disparities. Other interesting findings reveal that less than 5% of all veterans identified as being eligible for the MOVE program elected to participate (Littman, et al, 2012). Problems and Objectives It is important to point out that, “Veterans with PTSD frequently pursue service-connected disability benefits and may therefore attempt to document medical problems by reporting more symptoms, which may lead to more extensive medical evaluations” (David, Woodward, Esquenazi & Mellman, 2004, p.85). This is relevant as, further in the context of this research hypothesis, it will be revealed that service-connected veterans (such as those with PTSD) not only overuse health care but also are far less likely to actively participate in preventative health and wellness programs. The significance of this project will be to point out the implications of overlooking PTSD as simply a mental health disorder. The hope is to see that there is a strong, statistical correlation between PTSD and obesity. There is compelling research to suggest that PTSD is associated with obesity, osteoarthritis, heart disease and diabetes (David, et al., 2004). PTSD Associated with Diabetes and Obesity The VA/DoD Clinical Practice Guideline for Screening and Management of Overweight and Obesity states that “Overweight and obesity are associated with increased prevalence and worsening of several obesity-associated conditions, including type 2 diabetes” (VA/DoD, 2014, p.8). Since diabetes is strongly correlated with obesity, it is important to include this group in
8. PTSD AND OBESITY IN VETERANS 8 this comprehensive research. Many diabetics are at high risk for amputation and, according to Richardson, et al., over 50% of amputations can be prevented (2014). Summary of Problem Description The cost savings associated with preventative care for military veterans is critical. As Geiling, Rosen and Edwards state in their study, “If we treat a veteran’s PTSD at age 21, with counseling and lifestyle interventions”, it could prevent self-destructive behaviors (2012, p.1241). This type of proactive approach may save the healthcare system from having to fund treatment for largely preventable health disparities (Geiling, et al., 2012). Section B: Literature Support Introduction to Literature Support After working through the reference list that was created for the Evidence Based Research Project, this section will provide an appraisal for each resource that provides critical criteria to support the hypothesis. A variety of these sources confirm that veterans are becoming alarmingly more obese than their non-military counterparts (Almond, et al., 2008). The question of why veterans in particular are at greater risk for obesity is of great concern. The primary question, again, for this investigation is to determine: Are veterans who suffer from Post Traumatic Stress Disorder (PTSD), compared with veterans who do not suffer from PTSD, at higher risk for developing obesity? Initial findings support this hypothesis. In addition, there are troublesome statistics that project the increased costs associated with treating these veterans over time. And finally, the Veterans Administration (VA) health care system’s solution to this problem may not be enough to win this battle.
9. PTSD AND OBESITY IN VETERANS 9 Description of the Search Method Multiple databases were used to search for various studies and research in connection with this particular subject. This writer met individually with the staff librarian, Loretta Grikis, at the VA Medical Center in White River Junction, VT to review data and research. In addition to this, several searches were performed using various databases such as: Scholarly Search via Google, PubMed, ProQuest and the VA Medical Center’s Knowledge Library which is linked to virtually every database listed in the text book. Key search terms included words such as: Veteran, Obesity, PTSD, Military, Evidence- Based Research, Diabetes and MOVE! Various search terms were initially included at the onset of the research specifying tours and theaters (theater of war or operation). These were abandoned based on the exclusionary nature of the data that specific tours and theaters yielded. Summarization of ResearchStudies Used as Evidence The following studies represent the most essential in support of the hypothesis. The studies are listed alphabetically by the authors’ last name. Components of each study are described so that readers may evaluate the scientific merit of each, including its strengths and limitations. 1. The prevalence of overweight and obesity among U.S. military veterans by, Almond, N., Kahwati, L., Kinsinger, L. & Porterfield, D. (2008). Military Medicine, 173(6), 544-549 Article Summary
10. PTSD AND OBESITY IN VETERANS 10 The prevalence of overweight and obesity in veterans are an enormous cost burden for the Department of Defense (DoD). At the time this article was printed, the estimated budget was approximately $36 billion and projected to be double that number today. Design, Strengths and Limitations The study used a multivariate analysis of data retrieved from the Behavioral Risk Factor Surveillance System (BRFSS). A large, cross-sectional, randomized survey of veterans and non- veterans of men and women of all races, ages and income ranges were chosen to best represent a non-biased group. The results showed that male veterans overall have higher reported percentage of obesity than their non-veteran counter parts. Female veterans, on the other hand, have a lower percentage of obesity compared to their non-veteran counter parts. Key findings indicated that males, specifically between the ages of 35-54, tended to be more obese than non-veteran counterparts. The authors admit to several limitations in the study to include much of the data being self-reported. The overall strength of the study involves the reported trajectory of overweight and obesity with regard to the veteran population. As Almond, et al states, “Understanding this trajectory may inform not only the development of military primary preventive efforts but also nonmilitary behavioral modification programs” (p. 5). 2. Impact of VA Weight Management Program for Veterans by, Dahn, J., Fitzpatrick, S., Llabre, M., Apterbach, G., Helms, R., Cugnetto, M., Klaus, J., Hermes, F., and Lawler, T. (2011). North American Association for the Study of Obesity (NAASO). Article Summary
11. PTSD AND OBESITY IN VETERANS 11 Managing Overweight/ Obesity for Veterans Everywhere (MOVE) is a weight management program specifically designed by the VA and targeted for overweight and obese veterans. The study confirms successful weight loss of those veterans who participated in the MOVE! Program. The study further suggests that those veterans who actively participated in the SGS program following the initial SMS education group lost more weight. Design, Strengths and Limitations This was a quasi-experimental study using a pre and post-test for participants. The data gathered in this study analyzed the implementation and efficacy of the MOVE program in Miami. The significant drawbacks to this study are that: It only reflects 3, 6 and 12-month look backs at participants. The study was conducted for 27 months overall The study looked only at one VA Medical Center and is not representative of all VA centers. 3. Comparison of Comorbid Physical Illnesses Among Veterans With PTSD and Veterans With Alcohol Dependence by, David, D., Woodward, C., Esquenazi, J. and Mellman, T. (2004). Psychiatric Services. 55(1). Pp. 82-85. Article Summary An in-depth study correlating chronically ill patients with PTSD and those with alcoholism, this particular article focuses on the impact each of these mental health related disorders has on veterans. It further dissects each specific disease and associated risks of heart disease, osteoarthritis, diabetes and liver disease. The information in this study specific to the research and hypothesis is related to diabetes.
12. PTSD AND OBESITY IN VETERANS 12 Design, Strengths and Limitations The design of the study was a systematic chart review of male veterans who were admitted to a rehabilitation unit in the Miami Veterans Affairs Medical Center for chronic PTSD (N=55) or for alcohol dependence (N=38). They found a prevalence of diabetes among patients with PTSD (23%) that was significantly higher than other adult males aged 44 to 65 years in the general population (6%). The interesting findings associate PTSD with obesity, osteoarthritis, heart disease and diabetes well over those veterans with alcoholism alone. One limitation the study identified was that “Veterans with PTSD frequently pursue service-connected disability benefits and may therefore attempt to document medical problems by reporting more symptoms, which may lead to more extensive medical evaluations” (p.85). 4. Medical Costs of War in 2035: Long-Term Care Challenges for Veterans of Iraq and Afghanistan by, Gieling, J., Rosen, J. and Edwards, R. (2012). Military Medicine. 177(11). pp:1235-1244. Article Summary As evident by the title, the study is a projection of costs associated with veterans of the most recent wars. Not only is there a comprehensive breakdown of costs to care for these veterans, there is additional speculation about intangible costs such as family support. The evidence from this study that is most pertinent to the hypothesis lies in the research related to recognition and early treatment of PTSD and related disorders. Design, Strengths and Limitations
13. PTSD AND OBESITY IN VETERANS 13 The goal of the study was to “qualitatively list the medical costs of the war on terror and proactively target those costs that can [be] reduced using medical interventions” (p.1236). Most of the evidence is predictive and includes economic data projections. The specific data regarding PTSD patients is critical to the hypothesis for this paper. 5. CDC Evaluation of MOVE! Program for Veterans by, Littman, A., Boyko, E., McDonell, M. and Fihn, S. (2012). CDC-Preventing Chronic Disease. 0267(9). P.1-12 Article Summary This particular study suggests that MOVE! is not an effective tool for obesity treatment and prevention. The study also suggests that service connected veterans are less likely to seek assistance for weight management than non-service connected veterans. This information is important as it relates to a pro-active approach to weight management currently being utilized by the VA health care system in an effort to treat obesity.
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