Barriers to Weight Loss among Women Veterans with Obesity: An Exploratory Study
Rhea Saxena, CAS '25
Bachelor of Science: Global Public Health/Biology
Obesity is a prevalent health issue with complex, multifactorial causes and serious health consequences. Beyond being associated with several comorbidities such as heart disease and type 2 diabetes, obesity affects certain groups disproportionately. In the United States, women veterans in particular are disproportionately impacted by obesity, with the prevalence being about 44% among women veterans compared to about 40.3% in the general adult population (Batch et al., 2020; CDC, 2024). Thus, women-specific obesity care among veterans is important to evaluate. Studies have shown that women veterans are more likely to have disordered eating, have increased exposure to traumatic experiences, and have a serious mental illness (SMI) (Breland et al., 2017; Fitzke et al., 2024). In fact, in 2019, the prevalence of SMI was about 45% in women veterans and 31% in male veterans (Kreyenbuhl et al., 2019). This illustrates a clear need for healthcare interventions to address the complex health issues that women veterans face.
The percentage of women in the military has increased over the years, with the expectation that it will reach 14.3% by 2033 (Batch et al., 2018). Along with this increase, there is also an increase in women veterans’ usage of the Veterans Health Administration (VHA). Various resources are available at the VHA to address weight-loss goals for patients who are obese. One such resource is the Motivating Overweight/Obese Veterans Everywhere (MOVE!) program, which is a weight-loss program that uses evidence-based practices to implement healthy lifestyle changes (Batch et al., 2018). However, evidence-based approaches such as MOVE! “still do not adequately address the obesity epidemic in Veterans,” (Jay et al., 2015). This is especially true for women veterans, as most fail to lose a clinically significant amount of weight (over 5%) after enrolling in the MOVE! program (Batch et al., 2020). This is noteworthy because women are disproportionately overrepresented in the program (Batch et al., 2018). It is essential to understand why this disparity exists in weight-loss outcomes for women veterans, especially because it exists despite a “demonstrated interest in weight loss support through VHA,” (Vimalananda et al., 2016). This context leads to the critical research question: what are barriers to weight loss in women veterans with obesity?
Methods
In order to address the research question, a literature review was conducted to identify gaps and inform the research design. Two semi-structured qualitative interviews were conducted with two key informants from the MOTIVATE Research Lab. Due to the limited literature on barriers to weight loss in women veterans with obesity, the research question was informed by studies on related topics. These topics included women veterans living with obesity, healthcare barriers for women veterans, the impacts of military life on eating habits and other behaviors in women veterans, and the outcomes of weight management programs (such as MOVE!) in male and female veterans. One study encountered during the literature review, published by Batch et al., offered an evaluation of the MOVE! program in the context of outcomes in male and female veterans, which provided the most directly relevant data for the research question.
The two qualitative interviews were conducted with the Principal Investigator of the MOTIVATE Research Lab, Dr. Melanie Jay, and the Lead Research Data Associate of the WOOP VA study at the MOTIVATE Lab, Rachel Cansler. The MOTIVATE Lab researches interventions to address obesity, and the WOOP VA study is investigating the WOOP intervention for veterans with obesity in primary care settings. Dr. Jay, as Principal Investigator and practicing physician, provided a research and clinical-based perspective, while Rachel Cansler, as Lead Research Data Associate, offered insights from her direct work with patients.
The questions for Dr. Jay were crafted to gather data based on her experiences working as a physician with women veterans. Specifically, the questions pertained to what barriers to weight loss she had observed in her experience with women veteran patients. A few example questions that were asked include: What challenges exist for women veterans in meeting their healthcare needs? What are obstacles for women veterans that prevent them from participating and getting the most out of weight-loss programs like MOVE!? How do you think the VA addresses unique challenges for women veterans seeking obesity care?
The questions for Rachel were based on her experience working with veteran patients in the MOTIVATE Lab, inquiring about factors that prevented participants, including women participants, from staying consistent with the MOVE! program (as part of the WOOP study), as well as ways participation could be improved. Example questions that were asked include: Have you observed any challenges for women veterans in accessing and participating in MOVE!? Do you have suggestions for improving accessibility and/or retention for studies conducted with women veterans?
Results
After analyzing insights from the two key informant interviews and data gathered from the literature review, five themes were created to categorize the identified barriers to weight loss among women veterans with obesity. Table 1 presents the identified themes and barriers, providing an overview of the factors that affect weight management in this population. These factors include environmental, psychological, and sex-specific barriers.
Table 1
Identified Themes and Barriers to Weight Loss in Women Veterans
Theme | Barriers |
|---|---|
Military trauma | Military sexual trauma (MST) Post-9/11 combat trauma |
Lack of tailored care | Lack of tailored nutrition guidance Lack of clinics with women-specific care |
Logistical barriers | Caretaking obligations Transportation costs |
Serious mental illness (SMI) | Medications such as APMs and MSMs cause weight gain Psychological factors inducing shame and negative self-esteem |
Sexism | Sexism in the military Lack of understanding surrounding pregnancy in the military Sexism and harassment in healthcare settings |
Note. Sources: Batch et al., 2018; Breland et al., 2017; Fitzke et al., 2024; Jay et al., 2015; Kreyenbuhl et al., 2019.
Literature review
Military trauma
Women veterans have reported traumatic experiences in the military that have affected their experiences in healthcare settings and created a barrier to receiving resources such as weight-loss support. One significant such trauma is military sexual trauma (MST), which women find difficult to report due to shame and other stigmas surrounding these experiences (Fitzke et al. 2024). MST disproportionately affects women despite resources in the VA, such as screenings, to address this issue. As a result, many women veterans feel uncomfortable joining weight-loss programs that are co-ed or predominantly male, affecting their desire to enroll or continue with weight-loss programs (Vimalananda et al., 2016). In addition to MST, women after 9/11 were more likely to experience combat-related trauma, contributing to various behavioral health concerns that further affect their ability to utilize healthcare resources (Fitzke et al., 2024).
Lack of Tailored Care
Several studies utilizing qualitative interviews illustrate the lack of tailored healthcare and weight-loss support for women veterans. In a qualitative study conducted by Jay et al. (2015), a theme that impacted women veterans’ lifestyle choices was “unprepared[ness] to make health/life decisions,” as they did not have to worry about factors such as rent or medical care in the military, but they did after service. This unpreparedness results in unhealthier behaviors and provides a barrier for women who want to build healthy habits and lose weight after the military. Another theme emerging from this study was “tailored information,” which revealed that women veterans preferred dieticians who offered personalized care. One female participant said during the qualitative interview that the nutrition advice they had received “wasn’t specifically tailored to [her],” a concern that was brought up more frequently among women veterans than their male counterparts in the interviews. This barrier caused women to perceive that dietitians did not genuinely care about their needs, but rather were focused on merely fulfilling a requirement.
Logistical Barriers
Logistical barriers were noted by the key informants during the qualitative interviews. When asked about effects that the military had on women veterans, based on what she has observed in her career, Dr. Jay commented on how the transition from the military to life after the military is difficult psychologically: “All of a sudden, there is this transition where people don’t understand what you went through.” She explained that veterans have to figure out rent, eating habits, and other aspects of independent living that were “taken care of” in the military. Logistically, it is difficult to balance all of this for a veteran, and managing weight on top of this for women is even more difficult. Rachel was also able to share anecdotal insights into logistical barriers. In the WOOP VA study, women participants often miss appointments for reasons such as babysitting obligations, more often than men do, highlighting how these responsibilities disproportionately fall onto women veterans.
Serious Mental Illness
Women with serious mental illness (SMI) may be more likely to gain weight than men, and the side effects of psychiatric medications exacerbate this issue. According to a study conducted by Kreyenbuhl et al. (2019), 45% of women veterans at the VHA in 2019 had a SMI, compared to 31% of male veterans at the VHA. Input from both prescribers and patients was collected in this study, and several obstacles to weight loss were identified concerning SMI. One obstacle was the psychological aspect of weight gain and having an SMI. Many women veterans in this study reported feeling “self-conscious or unattractive, ashamed, guilty, and self-blaming.” These negative emotions, in addition to problems such as depression, anxiety, and low motivation, hindered women veterans from seeking weight-loss support. Additionally, weight gain is difficult to avoid for patients who are prescribed certain types of psychiatric medications, such as mood-stabilizing medications (MSMs) and antipsychotic medications (APMs) that have weight gain listed as a side effect. Furthermore, weight gain is often rapid once a medication is started. According to prescribers in the study, another factor impeding weight management is that with complex mental health issues and negative emotions, many patients are less likely to persist in achieving a difficult goal. This means women veterans with obesity and SMI are more likely to give up on losing weight. Additionally, veterans with mental health conditions such as depression and PTSD are more likely to engage in behaviors such as binge eating and emotional eating, which can play a role in weight gain and hinder weight loss (Batch et al., 2018).
Sexism
Sexism was found to play a significant role in inducing barriers to weight loss for women veterans. In a study conducted by Breland et al. (2017), women veterans were interviewed and asked about their eating habits after the military. According to testimony, overweight women end up in a “double-bind” when eating in military environments, because while the military enforced quick eating habits, overweight women would receive negative comments about the amount of food they would eat. One participant in the study stated: “you’re screwed no matter what you picked off the line…because if you ate junk they were going to come get you and… if you were going to eat healthy, you’re not going to have enough time to eat it.” The struggle with maintaining weight under the military’s maximum weight requirements was found to be associated with sexism as well, as men experienced less judgment and criticism than women about this requirement. Women also reported that they were “constantly judged on [their] appearance,” which is something that men in the military faced much less. Another form of sexism recounted by women veterans in this study surrounds pregnancy. There is a striking degree of insensitivity to women who become pregnant, as they are allowed to gain weight for the nine months of pregnancy, but are written up if they are still over the weight maximum six weeks after giving birth. According to a participant, “...they start writing you up, they start demoting you, but the men don’t have that [experience], you know?” Sexism in healthcare settings was also a theme noted during the literature review. In the study by Fitzke et al., one of the sub-themes identified as a barrier to healthcare for women was discrimination against women at the VA. A quote from one participant stated: “Being a female vet walking in there, you know, I would get eyeballed. ‘You’re a female, you don’t belong here.’” Instances like these hinder women veterans’ willingness to utilize VA resources.
Primary Data from Qualitative Interviews
The two key informants provided information and testimony to supplement and inform each of these five themes, in addition to the literature. The first key informant, Dr. Jay, discussed the fact that women go through many hardships in the military, which have long-lasting effects after service. Not only are there the physical and mental demands of the military, but women also experience MST, contributing further to their hardships. Additionally, she mentioned that women must use gear designed for men, causing them to have a higher likelihood of injury during combat. Dr. Jay also agreed with the finding from the literature that the pressure to “make weight” in the military leads to disordered eating and overexercising, signifying a hardship that causes poor habits after the military and serves as a key barrier to weight loss. She noted that many women veterans believe that weight loss is mainly about exercise rather than diet, since this is what they understood from being in the military, which leads to difficulties losing weight later on, as diet plays an important role in weight loss as well.
In addition to military-related barriers, Dr. Jay highlighted barriers involving the health system. She shared that she works in a women’s clinic at the Manhattan VA, which provides resources for gynecology, maternity care, and MST care (Women Veteran Care, 2024). However, this is not common among VA medical centers. The lack of women-specific care in many VAs acts as a barrier to addressing complex women’s health issues, leading to difficulty in achieving long-term health goals such as losing weight (Fitzke et al., 2024). Dr. Jay also recognized logistical barriers related to the health system, such as childcare responsibilities and transportation difficulties and expenses. These emphasize the importance of recognizing gender-specific logistical barriers in VA healthcare.
Lastly, Dr. Jay discussed social challenges that women face during and after the military. Stigma about being overweight or obese leads to hardships such as body image issues and the pressure to be thin, or to not be too thin, depending on different societal pressures and beauty standards. These social barriers pose psychological challenges for women veterans who want to lose weight.
The second key informant, Rachel Cansler, provided anecdotal insight about women veterans in the WOOP VA study and the MOVE! weight-loss program. When asked about what specific challenges women veterans face in accessing and participating in the MOVE! program, she said, anecdotally, that women tend to miss visits in the WOOP study (and likely MOVE! sessions, as well), due to caregiving responsibilities such as needing to babysit or watch grandkids. She also mentions, importantly, that habit formation is difficult, so barriers in accessing resources or reaching in-person appointments impact participants’ retention in research studies, and likely programs such as MOVE! that are intended for weight loss.
Discussion
This exploratory paper informs the critical research question using a literature review and semi-structured qualitative interviews with key informants. The themes that emerged from the research provide important insights into how women veterans with obesity uniquely struggle with weight loss. Traumatic experiences in the military, including MST, cause many women veterans to feel uncomfortable around male-dominated weight-loss programs and hinder women veterans’ willingness to participate, which illustrates the need for women-specific and trauma-informed care for women veterans.
The lack of tailored healthcare reveals how little understanding there is of women veterans' needs in weight management. For example, many women reported feeling dismissed by nutritionists in the study conducted by Jay et al. Women also highlight feeling that they did not know how to translate knowledge from dieticians to apply in their own lives, which shows that current resources are not sufficient to provide weight management guidelines. Women veterans have a unique need for individualized nutrition guidance that allows them to make realistic, sustainable changes to their lifestyle, while addressing any other barriers to weight loss that exist as well. Additionally, the lack of women's clinics in VAs was noted by participants in the study conducted by Fitzke et al., showing how women generally have a preference for healthcare environments that have women providers who cater to women-specific needs. These resources could help reduce the discomfort that many women veterans experience when entering a male-dominated environment, due to experiences of sexism and harassment or MST.
Certain logistical obstacles, such as caretaking responsibilities, fall disproportionately onto women. As a result, making in-person weight-loss commitments on time, or at all, becomes challenging. The solution to a barrier like this may not be simple, since there may be systemic factors playing into this disproportion. Transportation also poses an important barrier to accessing weight-loss support services, but unlike caretaking responsibilities, this affects both men and women veterans. These examples highlight that while certain logistical barriers are universal, others are more gender-specific and underscore a need for women-specific interventions.
Serious mental illness (SMI) was an important barrier that is not well understood in women veterans, primarily due to a lack of research in the area. But this causes a substantial barrier in women veterans trying to lose weight, due to both psychological and medication-induced challenges. Low self-esteem and shame surrounding SMI and weight gain contribute to the existing shame and stigma that surrounds being overweight or obese. When prescribed psychiatric medications, the “trade-off” between mental health and weight seems to be an impossible choice for many women, even though most would choose to take the medication despite the weight gain. This is a frustrating barrier, and as explained by Kreyenbuhl et al. in their paper, not only do the medications induce weight gain, but some can also decrease energy and make physical activity more difficult. This barrier presents a unique challenge in that not only does mental health care in women veterans need to be addressed, but also research and creation of new psychiatric medications that have less severe weight-gain side effects.
Lastly, sexism is an important barrier to weight loss in women veterans, as it is for many other subpopulations of women. Sexism in the military is a systemic issue that must be increasingly addressed as the percentage of women in the military increases every year. Experiences of sexism in the military lead to various behaviors that cause or impede weight loss in women veterans, such as poor eating habits and shame surrounding body image. The insensitivity to pregnancy in women and the lack of gear customized for women exacerbate the issue, showing how little attention is given to women-specific needs in the military. This illustrates how difficult it is for women to attain equitable resources and access to care in male-dominated environments, which causes long-lasting barriers to health for women. Sexism also leads to women veterans feeling uncomfortable in healthcare settings, such as the VA, especially when the setting is predominantly male. Co-ed or mainly male weight-loss groups (such as MOVE!) also make women veterans less likely to join, hindering their use of VA resources and their adherence to weight-loss support services. Addressing this barrier with women-specific care and providing women-only services may be a way to mitigate this barrier, so that women are not faced with a choice between comfortable care and weight loss.
Future Research
In the literature, many researchers have stated there is a lack of understanding and lack of published research on women, women veterans, and women living with complex health issues, including obesity and SMI. Further research is necessary in a few different areas in order to further address weight loss in women veterans with obesity. Weight-loss medications were not explored in much of the literature, likely because many successful and practical weight loss medications have only recently come about. One such type of medication is GLP-1 drugs, which Dr. Jay addressed during the qualitative interview. When asked about possible improvements to make weight loss more effective for women veterans, she shared that GLP-1 medications work better for women than men. This is supported by a study on sex-specific considerations for obesity management conducted by Kantowski et al. (2024), which proposed that females may respond more positively to weight-loss medications due to physiological characteristics. Additionally, the study reported that men tend to adhere better to lifestyle interventions than women. Thus, further research is needed to determine why the two sexes respond differently to different modes of weight-loss interventions, and to determine whether weight-loss medications such as GLP-1 medications are a justified alternative to lifestyle interventions in women veterans with obesity, given the context of the many psychological and environmental barriers they face in losing weight.
Additionally, more research is needed to determine whether women-only resources for weight loss will improve outcomes in women veterans. Drawing from a paper published by Vimalananda et al., research has shown that women would prefer women-specific care for PTSD and other chronic medical conditions. Thus, sex-specific care for weight loss may increase women veterans' retention in weight loss programs. Researching the outcomes of a women-only MOVE! program against the outcomes of the standard MOVE! program, for example, could provide insight into whether or not addressing the typical male environment in veterans’ resources will result in more weight loss for women veterans.
Given that women veterans make up a small percentage of the veteran population, recruitment of participants may pose a challenge. When asked about suggestions to improve accessibility to women veterans in the MOVE! Program and WOOP VA study (if it were a women-only study), Rachel shared that reaching out to women’s groups to recruit for studies and programs, and reaching out to women providers and women’s clinics, is important to increase women veterans’ participation in research. These methods could be employed in future research in order to attain an appropriate sample size for future studies.
Limitations
There are limitations to this exploratory study. Firstly, qualitative data was collected from only two key informants. Interviewing more informants may have provided more diverse perspectives to categorize and/or provided additional contexts for some of the barriers identified. Additionally, these informants were both part of the MOTIVATE lab, which may have introduced institutional bias. Data was not collected from women veteran patients directly, so the scope of this paper is limited as it does not include primary data from the population of interest. Secondly, the existing literature on weight loss in women veterans is limited, which constrains the depth of the data collected from the literature review. This may constrain the generalizability of the findings.
Conclusion
This exploratory paper identified barriers to weight loss for women veterans with obesity. After conducting a literature review and qualitative interviews with key informants, it was found that women veterans with obesity are faced with unique barriers that require innovative and well-researched solutions, such as trauma-informed care or GLP-1 medications. The results highlight where gaps lie in research on women veterans’ healthcare and inform where future research should be conducted.