Obesity prevalence among veterans at Veterans Affairs medical facilities

Obesity Prevalence Among Veterans at Veterans Affairs Medical Facilities Sandeep R. Das, MD, MPH, Linda S. Kinsinger, MD, MPH, William S. Yancy Jr, MD, MHS, Anthea Wang, MD, MPH, Eileen Ciesco, MHA, Mary Burdick, PhD, RN, Steven J. Yevich, MD, MPH Background: Obesity is a significant public health problem in the United States. Comprehensive obesity prevalence data among veterans have not been previously reported. Methods:

This is a cross-sectional analysis of 1,803,323 veterans receiving outpatient care at 136 Veterans Affairs (VA) medical facilities in 2000. Measured weight, height, and demographic data were used to obtain age-adjusted prevalences of body mass index (BMI) categories, which were stratified by gender and examined by age and race/ethnicity.

Results:

Of 93,290 women American veterans receiving care at VA medical facilities during 2000, 68.4% were at least overweight (body mass index [BMI]ⱖ25 kg/m2), with 37.4% classified as obese (BMIⱖ30 kg/m2), and 6.0% as class-III obese (BMIⱖ40 kg/m2). Of 1,710,032 men, 73.0% were at least overweight, 32.9% were obese, and 3.3% were class-III obese. Among women, obesity prevalence increased into the sixth and seventh decade of life before prevalence began to decline. Among men, prevalence was lowest for those aged ⬍30 and ⬎70. By race/ethnicity, Native American women (40.7%) and men (35.1%) had the highest prevalence of obesity, while Asian-American women (12.8%) and men (20.6%) had the lowest.

Conclusions: There is a substantial burden of obesity among veterans using VA medical facilities. A comprehensive approach for weight management by the Veterans Health Administration is needed. (Am J Prev Med 2005;28(3):291–294) © 2005 American Journal of Preventive Medicine

Introduction

O

besity is an escalating public health problem in the United States. As a risk factor for many chronic diseases, obesity is associated with increased morbidity.1 Obesity is also associated with early mortality and has been estimated to cause approximately 280,000 excess deaths among U.S. adults annually.2 Overall, obesity-associated expenses in the United States exceed $75 billion to $100 billion per year, with direct costs accounting for over 5% of all U.S. healthcare expenditures.3 Some have suggested that the public health impact of obesity surpasses that of smoking.4,5 The Veterans Health Administration is the largest integrated healthcare system in the United States, with 158 medical facilities and nearly 5 million active paFrom the Preventive Medicine Residency Program, Department of Social Medicine, School of Medicine, University of North Carolina at Chapel Hill (Das, Wang), Chapel Hill, North Carolina; and Veterans Affairs National Center for Health Promotion and Disease Prevention (Kinsinger, Ciesco, Burdick, Yevich), and Center for Health Services Research in Primary Care, Veterans Affairs Medical Center (Yancy), Durham, North Carolina Reprints not available. Address correspondence to: Linda S. Kinsinger, MD, MPH, Veterans Administration National Center for Health Promotion and Disease Prevention, 3000 Croasdaile Drive, Durham NC 27705. E-mail: [email protected].

tients. Comprehensive obesity prevalence data among veterans receiving care at Veterans Affairs (VA) medical facilities have not been reported. VA users have more comorbid illness than medical outpatients who receive care from non-VA facilities.6 Obesity may be related to comorbid illnesses both as a risk factor for, and also a consequence of, chronic illnesses and their treatment.7 Veterans who use VA facilities differ from the general population in other ways, being older, poorer, and less educated,8,9 which are factors that may also contribute to their risk for obesity. The objectives of the present study are (1) to determine the prevalence of overweight (body mass index [BMI] of 25 to ⬍30 kg/m2) and obesity (BMIⱖ30 kg/m2) among veterans using VA outpatient medical facilities; and (2) to examine the distribution and severity of obesity within this population in order to help target future public health programs.

Methods The VA Health Analysis and Information Group (HAIG) extracted height and weight data, entered by nursing staff during outpatient visits in 2000, from electronic medical records at 136 VA medical facilities, representing all regions of the country, that had agreed to participate in the data

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0749-3797/05/$–see front matter doi:10.1016/j.amepre.2004.12.007

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Table 1. BMI category by age and stratified by gendera Class-I obese BMI 30–34.9 kg/m2

Overweight BMI 25–29.9 kg/m2 Gender and age (years) Women (nⴝ93,290) ⱖ18 18–29 30–39 40–49 50–59 60–69 70–79 ⱖ80 Men (nⴝ1,710,032) ⱖ18 18–29 30–39 40–49 50–59 60–69 70–79 ⱖ80

% (SE)

n

% (SE)

n

Class-II obese BMI 35–39.9 kg/m2 % (SE)

n

Class-III obese BMI>40 kg/m2 % (SE)

n

28,916 2,330 5,211 8,360 5,172 3,046 3,377 1,420

31.0 (0.01) 30.0 (0.02) 31.5 (0.02) 30.3 (0.01) 30.2 (0.02) 30.8 (0.02) 34.4 (0.02) 31.3 (0.03)

19,750 1,168 3,458 6,288 4,068 2,328 1,834 606

21.2 (0.01) 15.0 (0.03) 20.9 (0.02) 22.8 (0.01) 23.7 (0.02) 23.5 (0.02) 18.7 (0.03) 13.3 (0.04)

9,507 436 1,547 3,222 2,208 1,199 699 196

10.2 (0.01) 5.6 (0.05) 9.4 (0.03) 11.7 (0.02) 12.9 (0.02) 12.1 (0.03) 7.1 (0.04) 4.3 (0.07)

5,608 150 702 1,940 1,595 814 340 67

6.0 (0.02) 1.9 (0.08) 4.2 (0.04) 7.0 (0.02) 9.3 (0.03) 8.2 (0.04) 3.5 (0.06) 1.5 (0.12)

685,909 7,861 24,264 70,853 142,534 157,412 215,680 67,305

40.1 (0.00) 39.0 (0.01) 38.5 (0.01) 36.5 (0.00) 36.8 (0.00) 40.3 (0.00) 43.7 (0.00) 41.7 (0.01)

379,112 3,885 15,324 45,543 95,677 96,937 100,709 21,037

22.2 (0.00) 19.3 (0.02) 24.3 (0.01) 23.5 (0.01) 24.7 (0.00) 24.8 (0.00) 20.4 (0.00) 13.0 (0.01)

126,918 1,192 5,652 18,095 38,349 33,367 26,247 4,016

7.4 (0.00) 5.9 (0.03) 9.0 (0.01) 9.3 (0.01) 9.9 (0.01) 8.5 (0.01) 5.3 (0.01) 2.5 (0.02)

55,905 368 2,627 9,666 20,565 14,027 7,822 830

3.3 (0.01) 1.8 (0.05) 4.2 (0.02) 5.0 (0.01) 5.3 (0.01) 3.6 (0.01) 1.6 (0.01) 0.5 (0.03)

a

Data for underweight and normal weight individuals are not shown; however, indicated percentages are calculated including these individuals. BMI, body mass index; SE, standard error.

collection project. These data were merged with demographic variables stored at the VA Austin Automation Center, and the combined raw data set, containing 3,800,828 patient records, was stripped of personal identification information. The 1,918,463 records lacking either a height or weight entry in 2000 were removed, leaving 1,882,365 records in the data set. Next, the 74,325 duplicate records arising from multiple medical encounters in 2000 were removed. Only information from the last encounter with complete data was retained. In order to exclude biologically implausible heights and weights, height was then restricted to between 48 and 84 inches (122 and 213 cm), and weight was restricted to between 75 and 500 pounds (34 and 227 kg), resulting in the removal of 4717 records. Thus, the final data set consisted of 1,803,323 unique individuals. Analysis was performed in 2003 using STATA, version 7.0 (STATA Corp., College Station TX, 2001). BMI was divided into six categories: underweight (BMI⬍18.5 kg/m2); normal weight (BMI⫽18.5 to ⬍25 kg/m2); overweight (BMI⫽25 to ⬍30 kg/m2); class-I obesity (BMI⫽30 to ⬍35 kg/m2); class-II obesity (BMI⫽35 to ⬍40 kg/m2); and class-III obesity (BMIⱖ40 kg/m2).10 Gender and age data were available for all patients. Race/ethnicity was not recorded for 42.6% of the patients. Comparisons of obesity prevalence among gender and racial/ethnic subgroups were age adjusted by using multivariate models to correct for the independent contribution of age to BMI. The Durham VA Medical Center (VAMC) institutional review board approved this study.

Results In light of the high prevalence of men in this cohort (94.8%), BMI category by age results are presented in Table 1 stratified by gender. Of the 93,290 women veterans receiving outpatient care at VA medical facili292

ties in 2000, 68.4% were at least overweight (31.0% were classified as overweight, and 37.4% were classified as class-I to -III obese). The prevalence of obesity increased with increasing age into the sixth decade of life and decreased substantially after age 70. The peak prevalence of obesity in women was 45.9%, seen in those aged 50 to 59, with 9.3% being class-III obese. In the 1,710,032 men, the combined prevalence of overweight and obesity was 73.0% (40.1% were classified as overweight, and 32.9% were classified as class-I to III obese). The observed prevalence of obesity among men increased with age into the sixth decade of life, but decreased substantially after age 70. The peak prevalence of obesity in men was 39.9%, seen in those aged 50 to 59, with 5.3% being class-III obese. Body mass index category by race/ethnicity results are presented in Table 2. Among women, Native Americans (69.8%) and African Americans (69.2%) had the highest combined prevalence of overweight and obesity, adjusted for differences in age, while Asian Americans (36.4%) had the lowest. There was a somewhat different racial/ethnic variation among men, with the combined prevalence of overweight and obesity being higher in Native Americans (73.9%), Hispanics (72.7%), and whites (72.5%), compared with African Americans (66.4%) and Asian Americans (58.8%), adjusted for differences in age.

Comments Obesity among American veterans is highly prevalent. Among women using VA outpatient medical facilities,

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Table 2. BMI category by race/ethnicity, adjusted for age and stratified by gendera Class-I obese BMI 30–34.9 kg/m2

Overweight BMI 25–29.9 kg/m2 Gender and race/ethnicity Women (nⴝ93,290) White African American Hispanic Native American Asian American Unknown Men (nⴝ1,710,032) White African American Hispanic Native American Asian American Unknown

% (SE)

n

% (SE)

n

Class-II obese BMI 35–39.9 kg/m2 % (SE)

n

Class-III obese BMI>40 kg/m2 % (SE)

n

11,584 3,742 673 72 140 12,705

30.8 (0.01) 34.4 (0.02) 39.1 (0.05) 29.1 (0.14) 23.6 (0.10) 34.1 (0.01)

8,187 3,013 379 65 56 8,050

19.5 (0.01) 22.2 (0.02) 18.3 (0.06) 22.4 (0.14) 9.1 (0.14) 18.0 (0.01)

4,160 1,472 183 37 17 3,638

8.9 (0.02) 8.9 (0.03) 7.5 (0.08) 11.1 (0.18) 2.6 (0.25) 6.8 (0.02)

2,737 752 94 28 8 1,989

5.1 (0.02) 3.7 (0.04) 3.2 (0.11) 7.2 (0.20) 1.1 (0.36) 3.1 (0.02)

314,968 61,222 23,310 1,402 2,320 282,687

38.9 (0.00) 36.3 (0.01) 42.8 (0.01) 38.8 (0.00) 38.2 (0.00) 42.0 (0.00)

177,065 35,875 11,810 878 821 152,663

22.3 (0.00) 20.3 (0.01) 21.4 (0.01) 23.4 (0.04) 13.7 (0.04) 22.7 (0.00)

61,676 12,825 3,492 323 290 48,312

7.8 (0.00) 6.8 (0.01) 6.2 (0.02) 8.2 (0.06) 4.8 (0.06) 7.0 (0.01)

28,444 6,107 1,392 149 134 19,679

3.5 (0.01) 3.0 (0.01) 2.3 (0.03) 3.5 (0.08) 2.1 (0.08) 2.7 (0.00)

a

Data for underweight and normal weight individuals are not shown; however, indicated percentages are calculated including these individuals. BMI, body mass index; SE, standard error.

two in three are overweight or obese, with more than one in three being classified as obese. Among men using VA outpatient medical facilities, nearly three in four are overweight or obese, with one in three being classified as obese. The prevalence of overweight in men is higher than that of obesity. In contrast, the prevalence of obesity is higher than that of overweight in women, as has been seen in other studies.11 The prevalence of overweight and obesity among veterans using VA outpatient medical facilities in 2000 was higher than in the general population. The 1999 – 2000 National Health and Nutrition Examination Survey (NHANES), using measured height and weight data, found that 61.9% of women were overweight and 33.4% were obese. Among men, 67.2% were overweight and 27.5% were obese.11 Results of the Behavioral Risk Factor Surveillance System (BRFSS) telephone survey in 2000 indicated a somewhat lower estimated prevalence of obesity (19.8%),12 likely because these estimates were based on self-reported data rather than measured data.13 Smaller studies of 1168 veteran patients at the Durham VAMC in 1999 (43% overweight and 36% obese), and 1731 veteran patients at the Minneapolis VAMC in 2003 (41% overweight and 34% obese), had results similar to the present study.14,15 The increased prevalence of obesity among VA users may be because the VA subjects were medical patients, while NHANES and BRFSS subjects were recruited from the community. The high prevalence of obesity in this population is notable. Obesity in adolescence often leads to obesity in adulthood16; however, these veterans were unlikely to be obese in early adulthood when they were required to meet military weight requirements. Understanding the reasons why these healthy weight levels did not persist into later adult years requires further exploration.

This population of VA-using patients is of particular interest for several reasons. First, its sample size is substantially greater than those in previously reported studies. Second, VA makes health care available to all veterans according to their eligibility status, thus minimizing the effect on health outcomes of lack of access to care. Eligibility for VA care is determined by extent of service-related conditions, being in one or more special categories of veterans, and income.9,17 Finally, the VA, as a large integrated healthcare system, allows a unique opportunity to test and implement systemic changes in medical care delivery to improve the health care of overweight and obese patients. The absence of race/ethnicity data for nearly 43% of patients is a limitation of the study. In VA administrative data sets, patients’ race/ethnicity is assigned by clerks, based on visual observation. An analysis of race/ethnicity in VA data sets found that administrative data agreed with self-reports over 90% of the time for whites and African Americans but only 20% of the time for Native Americans.18 Therefore, obesity prevalence rates for those classified as Native Americans may not accurately reflect rates for self-identified Native Americans. A second limitation is that some patients’ heights may have been self-reported, rather than measured. Given the tendency to over-estimate height,13 this would likely lead to an underestimation of calculated BMI. In light of the extent of the national obesity epidemic,19 and without a single easy and effective treatment, it is imperative that public health organizations develop more effective strategies to deal with this problem. The VA National Center for Health Promotion and Disease Prevention is developing an evidencebased, multidisciplinary, patient-tailored, weight management initiative to implement in VA medical facilities’ primary care clinics. This initiative is an Am J Prev Med 2005;28(3)

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What This Study Adds . . . The high prevalence of overweight/obesity in the general U.S. population has been well known for some time. This study provides new information showing that veteran patients seen in VA medical facilities also have a high prevalence of overweight/obesity. As the nation’s largest integrated healthcare system, the VA has an opportunity to develop, implement, and evaluate a population-level, multidisciplinary program for weight management and physical activity.

important first step toward reducing the large burden of obesity in VA-using patients. We wish to acknowledge the assistance of Mikeal Harrelson of the VA National Center for Health Promotion and Disease Prevention for his technical support in obtaining and preparing the data for analysis. The study was supported by the VA National Center for Health Promotion and Disease Prevention. WSY is supported by a VA Health Services Research Career Development Award. No financial conflict of interest was reported by the authors of this paper. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

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