Group Lifestyle Programs Reduce Obesity and Prediabetes in Veterans

by Bianca Garilli, ND, USMC Veteran

The estimated cost of diabetes in the US was $327 billion in 2017, which reflects both direct medical costs ($237 billion) and indirect costs ($90 billion).¹ After adjusting for inflation, this amounted to a 26% increase in diabetes costs from 2012 to 2017 and accounted for 1 in 4 healthcare dollars spent in the US.¹ In 2015 it was estimated that 30.3 million people of all ages, roughly 9.4% of the US population, had diabetes and another 5% had undiagnosed diabetes.^2,3

Diabetes in military veterans⁴

But it’s not just the general population who is impacted by these figures. In fact, military veterans have a higher diabetes prevalence than the general public, with 20.5% of veterans with diagnosed diabetes and another 3.4% with undiagnosed diabetes. Of those veterans who receive their healthcare through the Veterans Health Administration (VHA), a part of the US Department of Veterans Affairs (VA), nearly 25% were reported to have a diagnosis of diabetes. Among all veterans (seen at the VHA and outside of the VHA system), the highest rates of diabetes were found in veterans aged ≥65 years (27%), male veterans (22%), veterans with <12 years of education (33.5%), veterans with an annual income <100% federal poverty level (FPL) (23.8%), and Hispanic veterans (25.7%).

Research has indicated that lifestyle modifications focused on weight loss have the potential to prevent or delay the progression from prediabetes and metabolic syndrome (MetSyn) to the more advanced, chronic disease state of diabetes.⁵ Although it is well known that while on active duty or in the reserves, military personnel must maintain excellent physical fitness, it is less realized that the trend of a healthy lifestyle often does not continue once service members leave the military.⁶ The often dramatic shift in lifestyle results in elevated rates of obesity and subsequent MetSyn in this population.⁶ In fact, a recent publication indicated the presence of high rates of obesity (39.8%) and MetSyn (37.2%) in Air Force retirees within 8 years of leaving active duty.⁶

Obesity in military veterans

Turning to the obesity issue and its contribution to the diabetic state, the highest rates of obesity were observed in veterans ages 45-64 years (53.1%), male veterans (41.1%), veterans with <12 years of education (51.4%) and veterans who live below the 100% FPL (47.2%).⁴

Diabetes is the 7^th leading cause of death in the US and can be prevented through lifestyle modifications aimed at weight loss; programs that center around self-directed or coach-led approaches have been created and implemented within organizations that most frequently see and treat veterans, including the VHA.^3,5 Through body weight reduction, these programs have the potential to prevent or at least slow the progression from prediabetes and MetSyn to a diagnosis of diabetes.^3,5 The Diabetes Prevention Program (DPP) trial revealed that aiming for a 7% weight loss through intensive diet and exercise interventions could reduce the progression of prediabetes to diabetes by 58% over a 2.8 year time period.⁷ Further research uncovered characteristics common across the most effective lifestyle modification programs. These included:⁵

• Higher intensity programs demonstrated greater weight loss than the less intensive programs – greater intensity was found in programs implementing coach-led and self-study features
• Utilization of group interventions allowed for reduced costs for participants
• Implementation of specific behavior change strategies were associated with better outcomes

Taking information gleaned from the DPP trial and combining it with knowledge of shared characteristics from other effective lifestyle programs, specific modifications were added to the existing DPP, and the Group Lifestyle Balance (GLB) program was conceived.⁵ This program includes specific, classroom-based training in lifestyle changes, including a low-fat/low-calorie diet, recommendations for exercising 150 minutes per week, and other behavioral modifications.⁵ The goal of the GLB program is to support participants in losing 7% of their initial body weight.⁵ The GLB has now been successfully employed in various settings and populations including, “a poor urban community, an underserved Latino population, Native American youth, YMCA sites, and programs delivered by diabetes educators in urban, suburban, and rural outpatient hospitals.”⁵

To learn about the application potential in the military population, specifically veterans, the GLB program was implemented at the Wilford Hall Ambulatory Surgical Center (WHASC), home to the US Air Force’s Diabetes Center of Excellence (CDOE), the largest diabetes clinic in the Military Health System (MHS).⁵ A retrospective study was conducted to analyze the anthropometric and clinical outcomes for 704 baseline patients (61% female; 61% Caucasian; average age: 52) who completed the GLB program between January 1, 2009 and December 31, 2013.⁵

The GLB program consisted of 4 in-person monthly group sessions approximately 4 weeks apart, weekly self-study modules (including DVD/CD with video instructions for each week’s topics, supplemental information, and printed course materials), and weekly interaction with a lifestyle coach via telephone or secure messaging system.⁵

At the end of the 12-week program, the following results were found:⁵

• 364 participants completed the program (51.7% of initial participants)
• There was a statistically significant amount of weight loss, averaging 4%
  • Average weight loss was 3.43 kg
  • 9% of completers achieved at least 5% reduction in body weight
  • 4% achieved ≥7% reduction in body weight
• BMI significantly decreased from 31.53 kg/m² at baseline to 30.31 kg/m² at completion
• Significant improvements in waist circumference, fasting blood sugar, HbA1c, and cholesterol markers
• No significant change in blood pressure

Also worth noting are the findings related to prediabetes prevalence, which fell by 2.0%; obesity rates, which were reduced by 8.7%; and MetSyn prevalence, which decreased by 6.8%.⁵

The authors of this study conclude that the GLB program was effective at improving clinical outcomes and for reducing the incidence of prediabetes, obesity, and MetSyn for many who participated in the full extent of the program; therefore, this group lifestyle program approach should be considered across the MHS to reach more active duty and veteran service members who are at high risk for these preventable chronic diseases.

It is important for community and VHA providers to screen all military members and veterans for diabetes, prediabetes, and MetSyn, since this population has a higher prevalence of diabetes than the general public. Providers treating military service members and veterans within the MHS, VHA, and in the general community should implement lifestyle programs aimed at losing at least 7% of initial body weight. Prediabetes and MetSyn in the veteran population have been shown to respond well to high intensity, group-intervention, health-coach led lifestyle management programs, resulting in lower rates of and longer time to diabetes diagnosis.

Citations

1. American Diabetes Association. Economic costs of diabetes in the US in 2017. Diabetes Care. 2018;41(5):917-992.
2. Menke A et al. Prevalence of and trends in diabetes among adults in the United States, 1988-2012. JAMA. 2015;314(10):1021-1029.
3. National Diabetes Statistics Report, 2017. http://www.diabetes.org/assets/pdfs/basics/cdc-statistics-report-2017.pdf. Accessed November 14, 2018.
4. Liu Y, Sayam S, Shao X, Wang K, Zheng S, Li Y, et al. Prevalence of and trends in diabetes among veterans, United States, 2005–2014. Prev Chronic Dis 2017;14:170230.
5. Wardian J et al. Evaluation of the group lifestyle balance program in a military setting: an investment worth expanding. Mil Med. 2018;183(1-2):e138-143.
6. Cranston MM et al. When military fitness standards no longer apply: the high prevalence of metabolic syndrome in recent Air Force retirees. Mil Med. 2017;182(7):1780-1786.
7. Knowler WC et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.

Bianca Garilli, ND, USMC Veteran

Dr. Garilli is a former US Marine turned Naturopathic Doctor (ND). She works in private practice in Northern California and consults with naturopathic and Functional Medicine leaders, including the Institute for Functional Medicine and Metagenics. She is passionate about optimizing health and wellness in individuals, families, companies and communities- one lifestyle change at a time. Dr. Garilli has been on staff at the University of California Irvine, Susan Samueli Center for Integrative Medicine and is faculty at Hawthorn University. She is the creator of the Military and Veteran Health Initiative and is the current Past-President of the Children’s Heart Foundation, CA Chapter.