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This Issue: Chronic Disease Care | Table of Contents: Spring 2017 | Download this issue

Spotlight on Career Development Awardees

Improving Veteran buy-in to prevent diabetes

Career development awardee Dr. Jeffrey Kullgren is a research scientist at the VA Ann Arbor Healthcare System in Michigan. <em>(Photo courtesy J. Kullgren)</em>
Career development awardee Dr. Jeffrey Kullgren is a research scientist at the VA Ann Arbor Healthcare System in Michigan. (Photo courtesy J. Kullgren)

Career development awardee Dr. Jeffrey Kullgren is a research scientist at the VA Ann Arbor Healthcare System in Michigan. (Photo courtesy J. Kullgren)

Dr. Jeffrey Kullgren is a VA research scientist and an internal medicine physician who treats patients and teaches medical students at the VA Ann Arbor Healthcare System in Michigan. He is also on staff at the University of Michigan School of Medicine. When not with patients, he spends most of his work time doing health-services research, focused on improving both patient and physician decision-making about healthy behaviors and use of the Healthcare system.

VARQU recently spoke with Kullgren about his five-year, Career Development research award.

Dr. Kullgren, what area is your Career Development award in?

My Career Development award is focused on diabetes prevention and it's specifically focused on improving the engagement of Veterans who are at high risk for developing type 2 diabetes in the future. I am trying to improve their engagement in behaviors that will help them reduce the risk of diabetes in the future.


  • Dr. Jeffrey Kullgren's research focuses on key strategies that can be implemented within the VHA to help at-risk Veterans commit to reducing their risk for type 2 diabetes.
  • Improving the engagement of Veterans who are at high risk for developing type 2 diabetes can help them become more successful in losing weight.
  • The study involves delivering different kinds of secure messages about diabetes prevention to Veterans who are at risk for type 2 diabetes.


Studies show the prevalence of diabetes varies by race and gender. How does that play out in the Veteran population?

Among the patients that we care for in the Veterans Health Administration (VHA), about one in four have type 2 diabetes—which is higher than the U.S. population in general. In the U.S. population I believe that it is more in the neighborhood of 10 percent. Now this is not the prevalence among all Veterans. That's out of the patients whom we see within the VHA, who choose to come to us for their care. So that being said, this is a very common chronic condition. Among the patients who we serve, certainly, within my primary-care clinic, it is one of the most common conditions that I care for. And when I see patients in the hospital, diabetes is often a contributor to the acute health problems that our hospitalized Veterans face.

Obesity is becoming a critical health problem in the U.S.—studies show that it is also a problem for Veterans. How does obesity contribute to prediabetes or diabetes in the Veteran population?

Overweight and obesity are two of the main risk factors for type 2 diabetes, as we age. We have obviously many older patients within the VHA. So that's the key risk factor. Certainly family history can be another key contributor, as well as a sedentary life style. Those people who are physically inactive can be at risk for getting type 2 diabetes in the future. There are a host of other risk factors, but I would say that a lot of the risks that Veterans have that can contribute to type 2 diabetes are shared within the U.S. population. So the risk factors that our patients have are very similar to those that are seen outside of the VA.

So it is an important problem, but not one that is unique to Veterans?

That's right. But there are some other things that are unique to Veterans, but the main drivers of the development of diabetes are shared with the U.S. population.

Could you expand on that statement? What conditions are unique to Veterans?

I think that many of the patients that we care for in the VA face a host of unique health problems, many which could be related to their time in the service. So for example, many Veterans who have type 2 diabetes are service-connected for that condition because they may have been exposed to Agent Orange in the past. That's a known risk factor for development of diabetes. We also know that chronic pain and degenerative joint disease, which can be often related to one's time in the service because of the intense physical strain that can come along with that, can make it difficult for people to be physically active. I mentioned having a sedentary lifestyle can be a risk factor for developing diabetes. So that's another example of something that is seen in the general population, but in particular, does affect a lot of patients.

Dr. Jeffrey Kullgren and his research team at the VA Ann Arbor Healthcare System in Michigan. <em>(Photo courtesy J. Kullgren)</em>
Dr. Jeffrey Kullgren and his research team at the VA Ann Arbor Healthcare System in Michigan. (Photo courtesy J. Kullgren)

Dr. Jeffrey Kullgren and his research team at the VA Ann Arbor Healthcare System in Michigan. (Photo courtesy J. Kullgren)

Can you tell us about your study and the strategies you will use to help Veterans become more engaged in their Healthcare to prevent diabetes?

Research has shown us that people who are at risk for developing type 2 diabetes in the future, but don't yet have it, can significantly reduce their risk by losing a modest amount of weight and engaging in regular levels of moderate physical activity. So specifically, people who are at risk and are able to lose 7 percent of their body weight, who are able to get 150 minutes of moderate levels of physical activity a week—and when I say moderate that is something like brisk walking—can reduce their risk for type 2 diabetes. We know that people who are able to do that consistently can cut their risk of diabetes by about half. And that now is what has spurred the rapid development, implementation, and dissemination of the diabetes prevention program by the CDC and related partners like the YMCA.

The problem, however, is when we look at research studies—there are very few people, both within and without the VA, that are taking some of those steps to reduce their risk. So we have a disconnect between the kind of health that people want for themselves over the future, the supports that we have available for them, and what they are actually doing. So my line of research is focused on why that is the case, and to test different strategies to help people who are at risk for getting diabetes in the future. I also want to make accessible to them supports to help them reduce their risk and be healthier in the future.

Why have Veterans been resistant to these types of prevention strategies? Is that problem unique to Veterans? Or is it a problem in the general population?

Yes, I would say that this is another of those issues that are not unique to VA. As I've mentioned before, for many people even though they desperately want to lose weight, it can be very difficult. Most of us have experience with trying to go to the gym and getting regular exercise, and that can be a challenge to do on an ongoing basis. Some of these things are difficult, for a range of complicated reasons, for everybody.

I will say to give you the full perspective on this issue, in my personal experience as a primary-care physician, having identified patients who have elevated blood sugars in the prediabetes range, I've often had patients who even though they've already wanted to lose weight, they've already wanted to be more physically active, when they hear they are close to developing diabetes, they've often taken major steps to try to lose weight in new ways or try to be more physically active. So I think hearing that information for many people can be a window of opportunity that can lead them to act differently than they did before.

Can you tell us about the strategies that you plan to test out to engage Veterans in healthy behaviors?

I think the question becomes, knowing about one's risk for type 2 diabetes, what kind of things could be done within the VA health system to encourage Veterans to take some of those steps to reduce that risk? Maybe it is enrolling in the VA's weight management program called MOVE!, which in its most recent iteration has incorporated some key elements of the diabetes prevention program that I mentioned earlier. Maybe it is Veterans deciding on their own to lose weight, or perhaps with the support of their primary-care team, or trying to be more physically active. Maybe it is going outside of the VA and enrolling in a diabetes prevention program in their community. Maybe it is talking to their primary-care team about whether a medication to reduce their risk for diabetes could be right for them.

Once you identify these strategies, how easily can they be adopted into clinical practice?

One of the most important factors that I think about when designing intervention strategies is what could realistically be delivered at low cost and at scale for a lot of patients within the existing systems that we have. Now that creates some constraints in terms of having to work with what we have. But I will say that if you are focused on changing the world and being able to reach a lot of people and improve their health, you need to recognize what's actually going to be possible to be implemented, and what would be simply out of reach.

What we are specifically doing in this study is we are testing some new experimental approaches to better encourage Veterans to reduce their risk for diabetes. We are delivering different kinds of messages for diabetes prevention for Veterans who are at risk for type 2 diabetes and we will deliver those messages through secure messaging (which is the VA's email system for patients and providers).

Is this done through the HealtheVet patient portal?

Yes. So we are going to be delivering different kinds of prevention messages that have an evidence base from other decision-oriented domains we think have significant promise to encourage more Veterans to reduce their risk.

We are going to be delivering different kinds of messages. We are going to vary those messages and what's contained in those messages within that study. So with all of the Veterans in that study— this is the follow-up study that we are currently developing—we will be testing different kinds of approaches to encourage them to reduce those risks.

I'll give you a few examples of those strategies. One important challenge that we face in encouraging people to reduce their risk for type 2 diabetes is that they may not feel any different because they have prediabetes or their blood sugar is a little bit elevated. For many people it's easy to feel like that is something they want to address, but it is something they can do in the future. It doesn't feel particularly urgent.

We will be delivering weekly secure messages about diabetes prevention to patients in the trial. Some of those messages—people will be randomly assigned to different groups—will sound more urgent, and some will sound less urgent, to see how much of a difference it makes. That's one factor: changing the urgency of the messages.

Another approach that we are testing is something called implementation intentions. This is an approach that has been developed by psychologists to help people take some concrete steps toward achieving a goal. When people intend to do something in the future, if you are able to spell out what you are going to do, when you are going to do it, and where you are going to do it, and you actually lay those things out and write them down, even if you don't receive frequent reminders about that, simply the action of thinking about it and writing it down on a piece of paper can make it easier for you to do it.

The third one is where I've borrowed insights from another field of psychology called self-determination theory. What self-determination theory posits is that motivation that comes from within (rather than outside) is more likely to be stronger to sustain long-term healthy behaviors. We can think of examples in our personal lives, things that you are internally, intrinsically motivated for are things that you do just for the sake of doing them.

When people feel like engaging in a behavior that is closely linked to things that they value, it's more likely that they will engage in that behavior. If you think, for example, about preventing diabetes, there may be patients for whom some of their main aspirations in life are to be good grandfathers, or to contribute to their community, or serve other Veterans. Everybody has core values and aspirations in life. So to the extent that we can help patients feel that preventing diabetes is congruent with what matters to them in life, avoiding diabetes in the future will help them better achieve some of those things. It will be more likely that people will take some steps to reduce their risk.

The fourth strategy that we are going to be testing is something called preference checklists. Preference checklists were a strategy originally developed to help people save for retirement. Retirement is an interesting parallel when thinking about diabetes prevention. Most if not everybody wants to live well in retirement and have a comfortable, healthy, happy retirement with the resources they need. But saving for retirement can be really challenging for people. It's also one of those things that are easy to kick down the road.

So what preference checklists are is essentially a priming exercise. It puts in front of people statements that encourage them to think of tradeoffs between the present and the future. They encourage people to think about the future more immediately. We think that because this is a similar kind of behavior with many similar features and challenges, that when it is translated into a diabetes context it can help Veterans to take action now, instead of hoping to do so at some point in the future.

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