Veterans and Diabetes
The VA’s focus on diabetes care, research, and training
When diabetes advocates talk about groups of people at higher risk for the disease, they usually mention certain racial and ethnic groups. They might bring up age or obesity as risk factors. But veterans span all demographics and, as a group, nearly a quarter live with diabetes.
The U.S. Department of Veterans Affairs (VA) reports that nearly one in four men and women (24 percent) who served their country have diabetes. That’s much higher than the 9 percent of all Americans who have diabetes.
There are a few theories as to why diabetes disproportionately affects veterans. For one, they have a higher rate of overweight and obesity than the general population: More than 70 percent of patients in VA facilities are overweight or obese. VA patients also tend to be older, have lower incomes, and have limited access to high-quality, healthy food—social disparities that can lead to greater diabetes risk, says Linda Kinsinger, MD, MPH, chief consultant for preventive medicine at the Veterans Health Administration’s National Center for Health Promotion and Disease Prevention. And the VA has been examining suspected links between type 2 diabetes and herbicides such as Agent Orange, which was used during warfare by U.S. troops in the Vietnam War, as well as other aspects of war that could increase veterans’ risks for developing diabetes.
Nearly 23 million veterans currently live in the United States, and 9 million are enrolled in the Veterans Health Administration, or VHA, with about 6.5 million seen each year. The VA offers medical facilities across the country to care for veterans, as well as education and other benefit programs that touch nearly every American family. The VHA is the largest health care system in the country, available to most veterans who served in the active military service—and who were not discharged dishonorably—and their families. (Find eligibility requirements and an application at va.gov/healthbenefits/apply/veterans.asp.) It includes 150 medical centers, more than 800 outpatient clinics, 135 community living centers (nursing homes), 278 vet centers (which offer counseling services for mental health and more), and 48 supervised living facilities for veterans who need assistance with activities of daily living.
“The VA actually has three missions,” says Leonard Pogach, MD, MBA, national director for medicine in the Office of Specialty Care in the Office of Patient Care Services at the VA. “The most important mission is patient care.” The VA’s other key missions are to train health care professionals (it trains more than any other system in the United States) and to continue health research. “We have a very active research portfolio,” he adds.
The VHA employs nearly 5,000 primary care doctors, and this past summer, the VA, working with Congress, launched a recruiting campaign aimed at adding more health care professionals to the roster. The VA has also led the charge in diabetes research, from the VHA diabetes guidelines first issued in 1997 (and updated in 2010) to the Veterans Affairs Diabetes Trial, often cited alongside the ACCORD and ADVANCE trials as important in making headway in understanding diabetes care and preventing complications.
But how do the three missions shake out when it comes to serving individual veterans with diabetes? Here are some stories.
Joe Migley, 33, of Topeka, Kansas, always knew he’d be a veteran. Twenty days after graduating high school, he left for Army boot camp. From there, he had assignments in Korea and Fort Riley, Kansas, and served two tours in Iraq.
It was on one of those tours, Migley says, that events unfolded that would eventually lead to him being diagnosed with a type of diabetes caused by trauma or injury to the pancreas. A vehicle he and some of his company were riding in rolled over an artillery shell, which set fire to the vehicle’s fuel line. Migley suffered first-, second-, and third-degree burns. And a few years later, when he was diagnosed with diabetes, his VA doctors linked his diagnosis directly to trauma he received in combat.
According to research from the National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health, trauma—say, if the pancreas receives a blow that damages beta cells—can cause type 1 diabetes. In fact, another soldier in the vehicle was also diagnosed with type 1 diabetes after the incident, Migley says. “They directly related it back to our time in Iraq,” Migley says. “And since it’s considered a service-related disability, it’s entirely covered.”
Got You Covered
VHA health benefit coverage is a complicated system: Disability compensation is a tax-free monetary benefit paid to veterans with disabilities that are the result of a disease or injury that happened or was aggravated during active duty. Veterans can also get compensation for post-service disabilities that are considered related or secondary to disabilities occurring in service and for disabilities presumed to be related to circumstances of military service, even though they may arise after service. (The best example of this is Vietnam War veterans’ exposure to Agent Orange, which has been linked to an increased risk of developing diabetes.) The bottom line: There are many levels of medical coverage, and each veteran differs in terms of eligibility.
Because Migley’s doctors linked his diabetes diagnosis back to his service in Iraq, his insulin pump and supplies are covered. That is not the case for all veterans.
Joshua Vonkageler, 32, of Lakewood, California, an Air Force veteran, was diagnosed with type 2 diabetes last year. Throughout his service, which ended in 2008, he was told his blood glucose levels were “borderline,” but he says the seriousness of the diagnosis was never emphasized enough for him to make lifestyle changes.
In 2013, he was diagnosed with type 2 diabetes. And while the disabilities Vonkageler incurred in his years of service are covered by VA benefits, his diabetes supplies are not. He pays for them out of pocket.
“Now I can’t get rid of it, but I could have prevented it,” Vonkageler says. He says he’s been given educational materials, but hasn’t gone to any other type 2 support groups or programs that are directed toward veterans like him.
With the Program
Diabetes education programs do exist in the system. Kinsinger says that about a decade ago, the VHA started focusing not just on diabetes treatment, but also on comprehensive lifestyle management to help prevent and manage type 2 diabetes. “[Such programs are] available in all of our facilities, probably more than any large health care system has,” he says.
Part of what makes these programs helpful is their ability to be individualized, says Lynn Novorska, RD, LDN, the MOVE! dietitian program coordinator at the VA National Center for Health Promotion and Disease Prevention. MOVE! is a weight management program designed by the VHA to help veterans lose weight, with 10 sessions held over several weeks. According to Novorska, about 38 percent of veterans enrolled in the VHA are overweight, and 41 percent are obese.
While not specifically targeted toward veterans who have diabetes or prediabetes, Novorska says the program can be tailored to meet those veterans’ needs. The program also takes many cues from the Diabetes Prevention Program, a randomized clinical trial that showed the effectiveness of making lifestyle changes in order to delay or prevent the onset of type 2 diabetes. MOVE! focuses on lifestyles changes, from making smart food choices to getting and staying active at a variety of ability levels. The program is offered in several formats: one-on-one sessions with dietitians, group meetings, sessions that focus on dealing with weight plateaus, and options for disabled veterans to get more exercise.
About 580,000 veterans have participated in MOVE! through 4.5 million encounters (such as group meetings or one-on-one sessions with health care professionals or peers) in clinical settings in the VHA.
Amy Eisenbeisz, MS, RDN, CDE, has seen the results of the MOVE! program firsthand. As the MOVE! program coordinator for the Sioux Falls, South Dakota, VA Health Care System, she completed her master’s degree in nutrition based on her own research with MOVE! She found that between veterans who participated in MOVE! and those who qualified but did not participate, the participants were able to lose an average of 30 pounds more than the control group after one year, and they maintained nearly all of that weight loss at the two-year mark. She also saw significant improvements in participants’ A1Cs (a measure of diabetes control), overall cholesterol, and HDL (“good”) cholesterol after one year.
Eisenbeisz’s VA center also offers a two-day diabetes education course for veterans with diabetes. Taught by an interdisciplinary team including registered nurses, certified diabetes educators, dietitians, pharmacists, social workers, and integrative health leaders, classes may have more benefits than just education, Eisenbeisz says. “We have noticed that in group classes, our veterans greatly enjoy the support of the other veterans and seem to have a bond that we haven’t seen working with the civilian population,” she says.
Aaron Wright, 42, can attest to that. Before he was diagnosed with type 1 diabetes while on active duty in 1996, the Army veteran was constantly getting his uniform resized—because of weight loss. By the time of his diagnosis, his blood glucose level was higher than 900 mg/dl. “They went, ‘You’re lucky you’re alive,’ and I said, ‘Why?’ I was very uneducated,” Wright says. “They said, ‘We’ll bring you some books.’ ”
The VA did more than that. When working in Iowa (as a civilian in communications; Wright was honorably discharged in 1997), Wright often had group appointments with other veterans who had diabetes. While as a younger veteran with type 1, Wright could have been the odd man out (most veterans, like most people with diabetes, have type 2 and are older), but instead he found camaraderie. “I was not the only pump user,” he says. “There were about half a dozen of us that I saw on a regular basis. … There are a lot more insulin-dependent diabetic veterans than you know. I thought they were very supportive.”
Now living in Spencer, Louisiana, Wright is farther from that support group, but still has regular appointments with VHA doctors and gets a shipment of his diabetes supplies sent to him once every three months. Because he was diagnosed while on active duty, all of his supplies, including his pump, are covered by the VA.
While some veterans thrive on contact with each other, others find their own way. Robert Gift, 62, of Woodbridge, Virginia, has relied on the VA for plenty of medical care over the years and belongs to many veterans groups. But he says his support system is truly his wife of 38 years, Peggy.
“The VA has its problems,” says Gift, noting a tendency toward the status quo in treatment. But it’s also kept him going through thyroid disease, vision loss, two heart attacks, inoperable spinal disease, and type 2 diabetes. Now a federal employee, Gift, an Army veteran, gets all of his health care through the VA. He was diagnosed with “high sugar levels” in 1981, but wasn’t told he had diabetes until later.
While Gift has dealt with plenty of health issues and a rotating cast of health professionals—new doctors are often brought in for a 90-day rotation in the District of Columbia VHA facility—he’s also pleased to now have an endocrinologist and primary care doctor. He also met with an endocrinology team for the first time for a recent total thyroidectomy.
“I actually had two endocrinologists with me going over everything,” he says. “Both of them were firing questions at me and it was actually enjoyable. In those three weeks going up to surgery, I spent maybe six or seven hours with the endocrinologists. We talked more about the diabetes than what we did the thyroid.”
Whole-Body Health Care
Just like in the private sector, VHA health care providers treat the whole patient. “Many people are seen by multiple specialists: internists, podiatrists, ophthalmologists. [Their issues] might be answered in one or two visits, [or it] might be an ongoing relationship,” Pogach says. “[We’re] still responsible for the general overall management of the patient, day-to-day management of their conditions, [and] preventive services.” On top of that, VA doctors collaborate with social services to ensure veterans are served as best they can be. After all, they have served their country admirably.
By the Numbers
- Nearly 23 million veterans currently live in the United States
- 9 million vets are enrolled in the Veterans Health Administration, or VHA
- 6.5 million veterans are seen by the VHA each year
- 38% of veterans enrolled in the VHA are overweight
- 41% of VHA-enrolled vets are obese
To learn more about the Department of Veterans Affairs, visit va.gov.