A Call to Action: Intensive Lifestyle Intervention Against Diabesity

The ILIAD

The program can be called ILIAD: Intensive Lifestyle Intervention Against Diabesity. Homer’s Iliad tells the story of the Trojan War, a long, frustrating campaign that the Greeks finally won thanks to a successful and highly imaginative innovation (the Trojan horse).

What then would be the key characteristics of ILIAD? First, it would have to be provided at no additional cost to the patient. Simply telling VA patients to join a gym and buy better quality food is never going to work, even if we educate them regarding the long-term benefits. This is not to say that patient education should not be a component of ILIAD—it certainly should be. Second, it would have to provide rewards for the patients. Human beings do what they are rewarded for doing. A mechanism should be created so patients could receive cash payments or earn reward coupons for services and goods. Third, ILIAD should probably include an element of group dynamics, moderated by a knowledgeable group leader. Fourth, it would have to include a system of regular, frequent monitoring to provide feedback to both the health care providers and the patient. Such a monitoring system should make use of the most up-to-date, user-friendly digital technology and be available as a smartphone application. Finally, it would have to be designed so that it could be implemented across the whole spectrum of VA facilities.

The VA should create a working group to design and test ILIAD. While dedicated VA programs and facilities could be developed, it might be more cost-effective to provide membership for eligible patients in existing private-sector nutrition and exercise programs at existing neighborhood locations. These programs would have to be overseen and, perhaps, the details adjusted in collaboration with the private-sector partners to be more suitable for the VA patient population.

One advantage that VA has for implementing ILIAD is the CPRS. Another potential advantage is that all our patients have military experience. They have been through basic training. At some level, most know the benefits of discipline and regular exercise. In addition, there are veterans who were themselves trainers, ex-drill sergeants with experience in shaping up recruits and keeping troops fit. Perhaps this experience can be used in design and execution of ILIAD programs, even stressing a back-to-basics theme.

The VA currently employs the MOVE! program to encourage patients to improve their diets and engage in regular exercise. It has had notable success at some VA centers and has languished at others. The critical factor for a successful MOVE! program would appear to be the presence of a committed local “champion” and allocation of sufficient resources (personnel, space, dollars), which varies from center to center. ILIAD could be implemented as an “upgrade” (MOVE! 2.0), or as an alternative that would replace it. Unlike MOVE!, ILIAD would subsidize use of community resources, provide specialized trainers, and include a system of incentives and rewards for participation and success.

Without ILIAD, or something like it, the VA is inevitably going to be overwhelmed by the diabesity epidemic. There are simply not enough available medical providers or enough money in the federal budget to effectively treat all the patients using the medical model. If we do not innovate and think out of the box, we are doomed to fail, with enormous costs in terms of money to the system and, more important, in morbidity and mortality for our patients.

Let’s get moving. The time to act is now!

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.