We examined national trends in VHA MOVE! Weight Management Program participation before and during the COVID-19 pandemic, from January 2018 through January 2021. As anticipated, we found dramatic declines in MOVE! participation overall, particularly for in-person modalities, beginning in March 2020. This coincided with general national VHA guidance in mid-March 2020 to convert appropriate outpatient appointments to virtual modalities and subsequent MOVE!-specific national guidance to suspend in-person MOVE! visits for at least 30 days. The MOVE! program and providers responded rapidly, with 90% of participation transitioning to telehealth modalities by April 2020. In the initial months of the pandemic, telephone modalities accounted for the greatest proportion of MOVE! participation, but the share of anywhere-to-anywhere synchronous video (VHA Video Connect) participation increased over time. Compared with the same month in prior years, total monthly MOVE! participation (in person and telehealth) was 50% to 60% lower in April and May 2020. After May 2020, deficits relative to prior years generally became smaller over time (eg, approximately 40% lower in July and August 2020). However, MOVE! participation remained 20% to 30% lower in the latter months of 2020 and into January of 2021 compared with the same months in prior years.
The increase in VHA Video Connect participation over time was likely influenced by efforts to educate providers and patients on this newer technology as well as infrastructure improvements to increase bandwidth available for video appointments. The high utilization of telephone visits, particularly early in the pandemic, may reflect initial national guidance to use the modality with the lowest technology requirement (such as secure messaging or telephone) unless video visits had been established for MOVE! or a veteran preferred a video visit. Home telehealth (ie, TeleMOVE!) remained relatively stable over time. This stability was likely related to new COVID-19 home telehealth monitoring protocols that were developed and guidance to facilities to consider COVID-19 monitoring needs before enrolling new TeleMOVE! participants. At facilities where clinician resources were limited (eg, MOVE! staff reassigned to provide COVID-19 care), MOVE! teams were encouraged to prioritize telehealth options according to patient need and local context.
Our findings highlight that, although the VHA had existing telehealth infrastructure and programming, MOVE! participation in 2020 was 30% lower than in previous years. Therefore, many patients who would have otherwise received weight management services did not because of the pandemic. Given COVID-19–related declines in physical activity, increases in sedentary behaviors, and changes in eating patterns, there is a pressing need for accessible weight management services now and in the future.[9,10] Contributors to changes in health behaviors may include COVID-19 restrictions leading to shifts in routine or access to healthy foods and safe spaces for physical activity (eg, lack of access to gyms or exercise partners). Psychological distress also increased markedly during the pandemic, which may be a factor in worsening activity and eating behaviors, given that conditions such as depression and posttraumatic stress disorder affect health behaviors and weight.[10–13] Pandemic-associated stress may also lead patients to prioritize other aspects of their health (eg, coping with distress by eating comfort foods) and lives (eg, virtual schooling of children) over weight management. Related to these and other factors, 42% of US adults reported gaining unwanted weight during the pandemic, with an average gain of 29 pounds. With high rates of mental health conditions, food insecurity, and limited social support, veterans may be especially vulnerable to COVID-19–related behavior change and weight gain.[14–18] Weight management programs, including MOVE!, may need to incorporate additional strategies to help participants overcome the challenges to modifying health behaviors in the context of heightened pandemic-related stress and anxiety.
Our findings also suggest that barriers to telehealth may remain at the patient, provider, or health care system level. One such potential barrier is the lack of technology necessary for telehealth weight management services. The most common telehealth MOVE! modality early in the pandemic was telephone, but use of anywhere-to-anywhere synchronous video increased over time. Veteran preferences for MOVE! participation format and modality during and after the pandemic have not been broadly assessed. However, a survey among 58 veterans who were seen during the pandemic in an intensive weight management clinic that provides interdisciplinary pre- and postbariatric surgery care may provide some insights. In that study, half of participants indicated telephone visits were as good as in-person visits, and a similar proportion said they would prefer to have all visits over the telephone even after pandemic-related restrictions to in-person visits were lifted. Although participants were not offered video visits, they were queried about preferences for video. Nearly half indicated they would have preferred video to telephone visits if they were available, and 37% endorsed a preference for all video visits after restrictions were lifted. A substantial number of veterans lack the technology needed for video visits, including compatible devices or high-speed internet. These barriers differentially affect older, unhoused, and rural veterans. To address these gaps, the VHA implemented the Digital Divide Consult, which enables patients to obtain internet services or technology needed for VHA telehealth and provides robust technology support and digital skills classes. However, the VHA will need to evaluate the extent to which the pandemic exacerbated disparities in access and the success of the Digital Divide Consult in addressing these disparities. Given anticipated long-term shifts toward reliance on telehealth, the VHA must continue to ensure equitable access for all veterans.
Strategies to promote weight management access for VHA patients may include prioritizing a return to face-to-face modalities as soon as it is safe to do so and ensuring safe practices for face-to-face visits, especially group programs, in accordance with local and federal guidance, including use of face masks, social distancing, proper ventilation, hand hygiene, and encouraging vaccination and boosters. Other strategies could include offering hybrid models with in-person and telehealth options; continuing to provide MOVE! via synchronous video and telephone; and expanding self-directed options, like app, online, or DVD-based programs, which have been effective in non-VHA settings and are currently being tested in the VHA.[24–26] Offering telehealth or hybrid options may also enhance access to weight management services in non-VHA settings, where telehealth modalities may be less robust than in the VHA. For example, of the nearly 2,000 Centers for Disease Control and Prevention–recognized Diabetes Prevention Programs, which lead to clinically significant weight loss, less than one-quarter have telehealth options. Health care systems can also consider delivering weight management programs — in person, telehealth, or hybrid — in nontraditional settings, such as within mental health care, to promote access among specific patient populations.
Our study has several important strengths and limitations. We had readily available data on a nationally implemented weight management program with hundreds of thousands of visits over several years, allowing for investigation of trends over time. We also had information on types of program participation, including several different telehealth options, which facilitated examination of uptake of individual telehealth modalities before and during the pandemic. Limitations include use of data aggregated at the national level, precluding examination of the influence of patient-, facility-, or regional-level characteristics on MOVE! participation or understanding variation in the effects of COVID-19 on MOVE! participation. Furthermore, our study did not allow for evaluation of patient attitudes about access and preferred modalities, barriers to service delivery, or patient outreach during the pandemic. Future work should seek to understand patient perspectives on weight management program participation during COVID-19 and evaluate facility- and regional-level differences in the effects of COVID-19 on participation. We also were not able to examine trends in self-directed MOVE! participation (eg, the MOVE! app), although there is insufficient evidence to determine whether self-directed weight management programs without a clinical component are as effective as clinical interventions. Our findings reflect data from a single large integrated health care system and may not be generalizable to other health care systems or weight management programs, particularly those that did not offer telehealth options before the pandemic. Lastly, information on one dimension of participation — the number of monthly MOVE! participants — was limited by the potential for participants to be counted more than once in a given month if they participated in 2 or more MOVE! modalities or formats. Because of the transition of MOVE! to telehealth in March 2020, patients were more likely to be duplicated in the early months of the pandemic, because they were more likely to participate in more than 1 modality. Relatedly, we could not calculate yearly totals for participants, because individuals would contribute data to each month in which they participated in MOVE!, leading to substantial overestimates of the total annual number of participants.
In this study, we found a rapid transition of the VHA MOVE! Weight Management Program to telehealth modalities at the height of the COVID-19 pandemic. Although the VHA had been delivering MOVE! via telehealth before the pandemic, we found a sizable gap in total MOVE! participation compared with prior years that persisted into January 2021. Findings suggest potential unmet needs for weight management now and into the future, some of which telehealth may be able to address. Additional research is needed to understand whether these gaps continue and the factors driving them (eg, patient-, facility-, and regional-level factors) to promote equitable access to weight management services.
This work was supported by Career Development Award number 16–154 (K.E.G.) and number 15–257 (J.Y.B.) from the US Department of Veterans Affairs, Health Services Research and Development Program. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government. No copyrighted materials were used in this article.
Prev Chronic Dis. 2022;19(3):E11 © 2022 Centers for Disease Control and Prevention (CDC)