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. 2025 Aug 23;58:103224. doi: 10.1016/j.pmedr.2025.103224

Weight management for Black United States Veterans: Employee and patient perspectives

Jessica Y Breland a, Valentina V Petrova b, Olivia Hicks b, Lamont Tanksley c, Michelle A Borowitz c, Dakota Houseknecht b, Na'’imah Muhammad b, Andrea L Nevedal d, Katherine D Hoerster b,c,e,f,⁎
PMCID: PMC12410167  PMID: 40918688

Abstract

Objective

Veterans who self-identify as Black (hereafter Black veterans) and use the Veterans Health Administration (VHA)’s MOVE!® Weight Management Program lose less weight than other veterans. Understanding factors affecting this difference could identify solutions.

Methods

We interviewed 18 MOVE! employees and 26 Black veterans who engaged in MOVE! in the United States of America (2022/2023). Separate semi-structured interview guides focused on three research questions: 1) What are Black veterans' experiences in MOVE!?; 2) What factors impact weight management?; 3) How can care be improved? Transcripts were analyzed using deductive/inductive coding and rapid analysis.

Results

Employees and veterans were satisfied with MOVE! experiences. Participants described social determinants of health that could affect weight management or weight loss disparities, including stress, negative interpersonal or institutional experiences, bias, cultural differences, and health care experiences. Employees and veterans noted care could be improved by adjusting materials to address culturally-relevant foods and several suggested more diverse MOVE! staff. Participants expressed interest in training for MOVE! staff and care tailored to preferences/needs.

Conclusions

To ensure veteran-centered care, MOVE! could increase its focus on general health and functioning, managing mental health and stress, culturally-relevant foods, and training. Ongoing engagement with veterans could support these efforts.

Keywords: Weight management, Veterans, Health disparities, Qualitative, Stress

Highlights

  • •

    MOVE! employees and veteran patients are largely satisfied with the program.

  • •

    Additional tailoring could improve MOVE! outcomes for all veterans.

  • •

    Joint focus on weight management and stress reduction could reduce disparities.

1. Introduction

The Veterans Health Administration (VHA) serves roughly 6 million primary care patients annually. VHA offers the MOVE! Weight Management Program for Veterans (MOVE!), which is free, evidence-based, and associated with weight loss and a reduced risk of cardiovascular disease (Jackson et al., 2017; Maciejewski et al., 2018). Adapted from the Diabetes Prevention Program, the standardized MOVE! program is available nationally and usually entails 12–16 weeks of group or individual treatment focused on the combination of dietary and physical activity changes, supported by behavioral self-management strategies (e.g., goal setting, monitoring, problem solving, stress management). VHA users who self-identify as Black or African American (hereafter referred to as Black veterans) have higher obesity rates (Breland et al., 2017) and are more likely to use MOVE! and nutrition clinics than veterans who self-identify as White (Breland et al., 2024a) (hereafter referred to as White veterans). However, Black veterans are less likely to lose at least 5 % of their baseline weight six and 12 months after intense and sustained MOVE! participation (e.g. White veterans had 1.55 higher odds of 5 % weight loss than Black veterans) (Hoerster et al., 2014). Outside VHA, there are similar weight loss disparities between Black individuals and individuals from other racial/ethnic groups (Fitzgibbon et al., 2012; Svetkey et al., 2012; Blackman Carr et al., 2022). A systematic review of Diabetes Prevention Program adaptations tailored for Black populations suggests family/peer involvement and stress management may improve outcomes (Samuel-Hodge et al., 2014), but further work is needed to understand disparities and improve care (Ng et al., 2024).

Social determinants of health are important drivers of health disparities (World Health Organization, 2025). Social determinants of health are factors that affect the environments where people “are born, live, learn, work, play, worship, and age” (US Department of Disease Prevention and Health Promotion, 2025) and are “neither positive nor negative;” they “affect everyone” (Alderwick and Gottlieb, 2019). Some populations are more likely to experience social determinants in ways that lead to negative health outcomes. For example, housing practices in the United States of America (USA) have led to many neighborhoods with high proportions of residents identifying as Black having limited access to healthy foods and safe environments to exercise (Breland and Stanton, 2022; Bailey et al., 2021). Additional information on how social determinants of health affect the weight loss disparities experienced by those who self-identify as Black is necessary to identify meaningful solutions and promote equitable access to patient-centered care. At the same time, relationships among social determinants of health (e.g., access to health-promoting resources, community-level disadvantage) and health outcomes are complex and dynamic (Alderwick and Gottlieb, 2019; Bailey et al., 2017; Adkins-Jackson et al., 2021). Therefore, this work must include qualitative analysis that allows for a rich understanding of how experiences and local contexts impact health management.

The present work entailed the qualitative analysis of interviews conducted among a national USA sample of VHA employees involved with MOVE! and Black veterans who previously engaged in MOVE!. We sought to answer three questions: 1) What are Black veterans' experiences in MOVE!; 2) What factors (e.g., social determinants, health care quality), are perceived by those veterans and VHA employees to impact weight management; and 3) How can care be improved to eliminate the weight loss disparities? Our prior work, using Photovoice methods (Breland et al., 2024b), illuminated changes suggested by nine Black veterans planning to start MOVE!, including a focus on tailoring recommendations to individuals' diets and de-emphasizing body mass index (BMI). One limitation to that work was that not all participants subsequently participated in MOVE! so their direct experience was limited. This work builds on the Photovoice findings by focusing on veterans who recently participated in MOVE! and by being the first to include complementary employee interviews. The goal was to highlight similarities and differences between employee and veteran perspectives thereby providing a more complete understanding of the MOVE! program and broaden the context for understanding and improving care.

2. Methods

2.1. Study design and population

This qualitative study focused on VHA employees and veterans via purposeful criterion sampling (Palinkas et al., 2015). Eligible employees were currently/previously affiliated with MOVE! as staff, clinicians, and/or leaders. Eligible veterans had to be VHA patients, identify as Black or African American, have started MOVE! within the prior 4–6 months, and completed at least 1 session. We excluded veterans for whom study participation would be challenging, e.g., those diagnosed with dementia or severe hearing loss.

2.2. Recruitment and consent

We recruited MOVE! employees by emailing members of two listservs (with some overlaps across listservs). We contacted 167 employees with 8 declining participation. Of the remaining, 21 scheduled an interview, 18 participated in an interview, and we never heard from the others. Employees were not paid, as they completed interviews during VHA time.

We identified potential veteran participants via the VHA medical record, sending a recruitment letter and information statement, which included information on opting out of further contact. We sent encrypted emails and mailed materials to 320 veterans. Of those: 26 participated, 12 declined participation, 3 were ineligible, and 56 were called but not reached or were reached, but lost to follow-up. Remaining veterans were not contacted due to reaching recruitment targets. Veterans were paid $40 for their time. Recruitment targets for employees and veterans were based on capacity to conduct interviews and the research questions (Morse, 2000).

This study was conducted in compliance with relevant regulations and approved by the VA Puget Sound Healthcare System Institutional Review Board (reference number: 1665637, 01/28/2022). We received a waiver of documentation of consent. Veteran and employee participants reviewed an information sheet and consented to audio recording over the phone.

2.3. Interviews

Employee interviews were conducted between July and September 2022 and veteran interviews were conducted in June and August 2022. The semi-structured interview guide for employees focused on their role with VHA and MOVE!, how well MOVE! works for Black veterans, and what could be changed to better serve veterans using MOVE! (see Appendix). One research assistant—a woman who identifies as White (GM)—conducted the employee interviews. The semi-structured interview guide for veterans focused on their experiences in MOVE!, how their daily life affected their experiences in MOVE! and with implementing health behavior changes and weight loss, and how MOVE! could be improved (see Appendix). Veteran interviews were conducted by one of four VHA employees who self-identify as Black: a male peer support counselor [LT], a woman psychologist [MAB], and two women research staff [OH and JB [not the first author; listed in acknowledgements]]. Participants were asked whether they wanted a man or woman interviewer.

Both employee and veteran guides ended with multiple-choice questions asking for input on potential changes to MOVE! (e.g., “Do you think inviting family and friends to MOVE! sessions would help Black veterans achieve their goals in MOVE!?” Answer options: yes, no, maybe). Participants were also invited to comment on why they made their multiple-choice selection.

2.4. Analysis

Veteran interviews were transcribed verbatim by an experienced staff member (RS) and then analyzed using deductive/inductive coding (Elo and Kyngäs, 2008) between December 2022 and July 2023. The lead [VP, woman who identifies as white, qualitative research expert] and secondary [OH, woman who identifies as Black, research assistant] analysts coded two interviews and discussed differences to agree on the use of deductive codes based on the interview guide (e.g., impact of daily life). Inductive codes were generated by both coders (e.g., camaraderie, resources/materials/handouts), with new codes discussed in weekly meetings to ensure consistent use of the full codebook. Weekly meetings also included a discussion of findings and both analysts kept memos related to the research questions, including participants' lived experiences with MOVE!, barriers and facilitators to health behavior change/weight management, and suggested improvements to MOVE!. Preliminary findings were shared with the co‑leads (a woman who identifies as Black [JYB] and a woman who identifies as White [KDH]) and two interviewers [LT and MAB] to discuss emerging patterns. Quality assurance to validate transcripts for accuracy was conducted simultaneously with coding by listening to audio and noting needed adjustments.

Of 18 employee interviews, five had poor audio quality. The latter were transcribed, but some details were filled in from context and others contained missing sections of data. Given these limitations, these five transcripts were included in analysis, but we did not take direct quotes from them. Due to related transcription delays and their shorter nature, employee interviews were analyzed with a rapid content analysis process (Kowalski et al., 2024) using a deductive matrix (Averill, 2002) with domains based on the interview guide. The lead analyst [VP] populated the matrix in Microsoft Excel with the first transcript; the remaining transcripts were split between two analysts [VP, OH] for review and matrix incorporation. The lead analyst [VP] then reviewed the full matrix and wrote the findings report, noting any inductively generated points of triangulation with and divergence from veteran data. Interview guides contained similar questions to facilitate this process. Analysis of employee interviews was completed between September and December 2023. Veteran analyses used ATLAS.ti for Windows (versions 22 and 23).

3. Results

We interviewed 18 MOVE! program employees across the USA (16 women, 2 men), generally in their 30s or 60s. Most were MOVE! coordinators and identified as White, with two identifying as Asian and two identifying as Black. We also interviewed 26 Black veterans who used MOVE! (16 women, 10 men) who were mostly in their 50s and 60s (range: 35–70). The mean number of prior MOVE! visits was 7 (SD: 6; range: 1–18). Most were from the Southern USA (Table 1). Average interview length was 30 min for employees and 45 min for veterans. We synthesized feedback to answer the three research questions 1) What are Black veterans' experiences in MOVE!?; 2) What factors impact weight management? 3) How can care be improved?

Table 1.

Veteran participant geographic regions based on Veterans Health Administration regions in the United States (data collected 2022/2023.

N
Region of the United States of America
 West 5
 Midwest 3
  Northeast 1
 South 17
 Alaska 0
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3.1. Research question 1: Experiences with MOVE!

When asked how MOVE! functioned for Black veterans at their site, many employees responded that they could not answer because they did not have data/statistics on MOVE! participation rates/outcomes, and/or that they had not looked into addressing their needs. Some employees assumed outcomes were similar between veterans who self-identify as Black and other MOVE! users. Two employees noted that they had developed programming such as “…a live cooking demonstration with our chef here, in doing soul food cooking, nutritious tasty meals.” (Employee A) as part of a partnership with the site's Healthy Teaching Kitchen (Healthy Teaching Kitchen Program, 2025).

Veterans' overall experiences with MOVE! were positive, as one participant said “I loved everything about MOVE!...the instructors and counselors are wonderful.” (Veteran A). They appreciated the camaraderie, accountability, focus on motivation, and resources the program provided. Veterans emphasized that MOVE! improved their overall physical and mental health through changes in diet and exercise. As one participant noted, “I have so many non-scale victories…[reduced pain]…swelling is gone. I'm not on blood thinners anymore…my overall health is, oh my gosh…I'll call it excellent.” (Veteran B).

3.2. Research question 2: Factors that impact weight management

MOVE! employees had varied reactions to information about the weight loss disparity experienced by Black veterans. Some wanted to see the data before reacting. Two employees and one veteran believed the disparity could, as an employee said, “be like a genetic predisposition”:

If Black, not Black veterans, but just the Black population in general have a more difficult time to lose weight, that could be a factor as well. For instance, I heard once, [inaudible], the Black population has a higher rate of [high] blood pressure than the White population. And that's more of a genetic predisposition. (Employee B).

Another employee linked the disparity to systemic issues impacting people identifying as Black in the USA, noting:

I think that in general we have these systemic issues in US healthcare in general, and at the VA in particular, about how supportive we are of Black veterans, even how much we understand and treat African American or Black veterans as a population.” (Employee C).

Veterans simultaneously described how race affected their designation as someone who needs weight management. As one veteran said, “…If you're Black, you're always morbidly obese [to healthcare professionals]. Whereas if another person weighed 200 pounds, they would definitely not write morbidly obese down by their name.” (Veteran C) Speaking of contexts outside VHA, another veteran said:

Well, racism has a lot to do with me losing my job. I work for [company name] I had a passenger that actually called me the N word…I went into a rage… I lost my job. That's what started my progression to gaining weight. Over 2 years I gained 80 pounds. I didn't want to go to the gym, I just didn't want to be around people. Because I just didn't like people for a while. (Veteran D).

For this veteran, it was negative interpersonal or institutional experiences in the broader world that affected weight and health behaviors as opposed to experiences within the health care system. At least one veteran noted that growing up in the Southern USA and “on the other side of the tracks” affected their diet in a way that was not specific to race, noting “I have White friends that eat just like me.” (Veteran B).

3.3. Research question 3: Future improvements

When asked how MOVE! could be adjusted to better serve Black veterans, some employees said they could not answer the question given that they did not have data on the disparity. Among employees with suggestions for improving MOVE!, ideas were often similar to those of veterans. For example, both employees and veterans thought MOVE! materials could be more representative. As a veteran said, “…they have pictures of my culture in the book, but the content of the book doesn't represent my culture...” (Veteran E). Several employees and veteran participants mentioned recipes that could change with one stating “…some of these recipes they put in there could stand a little bit of Black input…it would be nice to see, maybe this is a healthy version of something that Black people would eat.” (Veteran F).

Perhaps related, veterans and employees also agreed that “[hiring] more Black dietitians and facilitators” (Employee D) could improve the MOVE! experience. At least one veteran noted that they might have acclimated to the MOVE! group more quickly if there had been staff or participants identifying as Black, saying, “…I was looking for more African American instructors and counselors. You know, you tend to identify with someone at first, of your own race…” (Veteran A).

A few MOVE! employees expressed concern that their sites' outreach may be insufficient, due to the program not reflecting the experiences of Black veterans regarding both representative staff and curriculum. Other veterans wanted staff that could identify with mental health concerns, such as post-traumatic stress disorder (PTSD), or wanted family involved. Employee participants agreed with veterans on the importance of better addressing mental health.

Several employees discussed other recommendations for adjusting programming, for example, improving access to healthy foods with ideas such as food pantries at VA medical centers or community-based outpatient clinics, Healthy Teaching Kitchen cooking demos, farmers markets, and grocery store tours with a dietitian. Other ideas included improved access to exercise options, counseling for diabetes and pre-diabetes, and expanding MOVE! schedules (e.g., evening, weekend, and virtual options). Some discussed incorporating peer support, partnering with local organizations (e.g., YMCA), or incorporating Whole Health, i.e., aligning veteran's health goals with “their mission, aspiration and purpose” (Employee A).

Some participants noted the importance of avoiding stereotypical thinking and assumptions, listening to veterans, asking questions, and focusing conversations about weight management on health risks, such as diabetes, rather than focusing on BMI. As one participant said:

…the height and weight standards are just, I don't know, I think they can use a little adjusting…Yeah, so [at] my height and weight…then you're automatically categorized into obese, unfit. When I speak to doctors, they're looking at my blood pressure, they're like your heart is at optimal, you're extremely fit. But I'm overweight. And so then you're categorized as unhealthy, obesity. And I think a lot of that stems just from one size doesn't always fit all. (Veteran G).

Finally, employee and veteran participants were asked to answer yes, no, or maybe to a list of pre-specified potential changes to MOVE!. Results were generally aligned with interviews (Table 2). Notably, both employees and veterans felt that adding information on coping with stress and inviting family and friends would be important ways to improve MOVE!.

Table 2.

Participant responses to closed ended items⁎ (United States of America based sample in 2022/2023).

Do you think this potential change to MOVE! would help improve care for Black Veterans? Yes Maybe No
“A MOVE! program just for Black Veterans” 10 Veterans
6 Employees		 10 Veterans
10 Employees		 9 Veterans
2 Employees
“Having MOVE! co-delivered by Black Veterans who have experience with MOVE!” 16 Veterans
13 Employees		 6 Veterans
5 Employees		 6 Veterans
0 Employees
“Inviting family and friends to MOVE! sessions” 17 Veterans
12 Employees		 8 Veterans
5 Employees		 1 Veteran
1 Employees
“Incorporating strategies for coping with and managing mental health symptoms and general stress into MOVE!” 24 Veterans
17 Employees		 2 Veterans
1 Employees		 2 Veterans
0 Employees
“Incorporating support and strategies for coping with racism-related stress into MOVE!” 12 Veterans
8 Employees		 6 Veterans
8 Employees		 9 Veterans
2 Employees
“Incorporating more support for body acceptance and appreciation into MOVE!” 20 Veterans
13 Employees		 5 Veterans
4 Employees		 3 Veterans
1 Employees
“Offering MOVE! via a mobile app, website, and/or DVD” 22 Veterans
7 Employees		 3 Veterans
8 Employees		 5 Veterans
3 Employees
“Anti-bias training for MOVE! staff (Anti-bias training is intended to make people less likely to treat others unfairly, by addressing their preconceived notions they have about others based on characteristics like race, sexual orientation, gender, and body size.)” 18 Veterans
15 Employees		 9 Veterans
2 Employees		 5 Veterans
1 Employees
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⁎

Total responses for Veterans in this table sometimes exceed the 26 interviews because some participants gave more than one answer and their mixed responses are reflected in the table.

4. Discussion

Qualitative analysis of interviews with VHA employees and Black veterans suggests overall satisfaction with the MOVE! program. Participants described complex relationships between social determinants of health, like employment, negative interpersonal or institutional experiences, and experiences with health care, that affect weight management. Regarding specific recommendations, participants thought MOVE! materials should be updated to reflect the experiences of Black patients. The lack of employees who self-identify as Black involved in MOVE! was also identified as an area of potential improvement. Both recommendations align with prior work (Breland et al., 2024b).

These results build on existing work by including the perspectives of employees, which often matched those of veterans. For example, interest in cooking demonstrations related to foods commonly eaten in Black communities. The MOVE! program could more broadly partner with national Healthy Teaching Kitchen programs to make such programming universal. Perhaps relatedly, participants felt that the MOVE! materials had surface representation of Black veterans, but that the details of the content, particularly the recipes, did not reflect their lives. Findings suggest that future iterations of MOVE! materials could continue to be improved with input from veterans from all backgrounds.

Some employees (and one veteran) thought that weight loss and other health disparities could be due to genetic differences. Racial groups are socially constructed categories and as a result, genetic differences cannot account for race-related health disparities (Boyd et al., 2020). Additional training for MOVE! employees on factors that contribute to health disparities for all veterans could address this knowledge gap. These educational efforts could also focus on empowering employees to use data to identify and address potential disparities among veterans.

Both employees and veterans said that MOVE! should do more to address mental health conditions, such as PTSD, stress, and their effects on weight management. Black veterans experience disproportionately high rates of PTSD (Spoont and McClendon, 2020), which is associated with losing less weight during MOVE! (Hoerster et al., 2014). Therefore PTSD and more general forms of stress may contribute to weight loss disparities. There are current trials underway that address both weight and stress management, with at least one specific to patients who self-identify as Black (Hoerster et al., 2021; Buro et al., 2022). It is noteworthy that the MOVE! curriculum already includes a session focused on managing stress and finding support (Module 14, MOVE! Weight Management Program for Veterans). Continuing to integrate and enhance approaches for addressing mental health into MOVE! may help VHA better serve veterans.

The present study focused on the weight loss disparities experienced by Black veterans, however many of the identified solutions would also benefit all veterans. For example, tailoring recipes in MOVE! materials could also make them more applicable to regions where many people who self-identify as Black live (e.g., the southern United States). In addition, given that other groups, such as veterans who identify as American Indian or Alaska Native, also experience a disproportionate burden of PTSD (Korshak et al., 2025) and high rates of obesity (Breland et al., 2017), incorporating mental health treatment into MOVE! could have a broad impact.

As in some other work (Woodward et al., 2019), we found that when asked directly, veterans said racism did not affect care. At the same time, they noted that their race impacted their health and health behaviors, including how clinicians diagnosed them, available foods, and negative interpersonal or institutional experiences. Conversely, in our Photovoice work (Breland et al., 2024b), participants who identified as Black openly discussed harmful interpersonal and institutional experiences in and outside of VHA care. A key difference is that the Photovoice work included six, video-based sessions with the same veterans and facilitators invited to each session. The current work and a prior study (Woodward et al., 2019) relied on a single telephone interview. It may be that multiple in-person or video-based interviews or focus groups led by racially concordant staff facilitate trust and openness in conversations about difficult topics – a method that should be considered for future work.

Limitations of the present study include a focus on VHA users who, in addition to being older than the average person in the USA, have access to free, evidence-based weight management care. However, the national sample and the ability to include participants who self-identify as Black offset this limitation. An additional strength is the use of close-ended responses to summarize and compare responses between employees and veterans. These data also highlight employee and veteran interest in body acceptance and stress management. Audio issues with employee interviews limited our ability to include employee quotes, although this concern is balanced by including all interview transcripts in analysis to ensure all perspectives were captured. Finally, findings should be interpreted with the knowledge that behavioral weight management outcomes other than weight loss are important, including function and the management of chronic conditions, like diabetes and hypertension. Future work should determine whether the weight loss disparities experienced by Black veterans also affect these outcomes, and whether weight loss is the highest priority goal for them when entering MOVE!.

5. Conclusion

Differences in weight loss experienced by Black veterans using MOVE! may result from social determinants of health in their everyday lives. To ensure optimal, veteran-centered care, MOVE! could increase its focus on general health and functioning, managing mental health and stress, cooking/eating culturally-relevant foods, and training (e.g., on de-emphasizing BMI). Ongoing engagement with veterans could support these efforts.

CRediT authorship contribution statement

Jessica Y. Breland: Writing – review & editing, Writing – original draft, Funding acquisition, Conceptualization. Valentina V. Petrova: Writing – review & editing, Methodology, Formal analysis, Data curation. Olivia Hicks: Writing – review & editing, Formal analysis. Lamont Tanksley: Writing – review & editing, Investigation, Data curation. Michelle A. Borowitz: Writing – review & editing, Investigation, Data curation. Dakota Houseknecht: Writing – review & editing, Project administration, Data curation. Na'’imah Muhammad: Writing – review & editing, Project administration, Data curation. Andrea L. Nevedal: Writing – review & editing, Conceptualization. Katherine D. Hoerster: Writing – review & editing, Writing – original draft, Supervision, Project administration, Methodology, Investigation, Funding acquisition, Data curation, Conceptualization.

Funding

This project was funded by intramural funds from the Veterans Health Administration.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

We thank Alan Wesley, Eric Epler, Rachel Smith, Juliana Bondzie, Gillian Monty, and Nadiyah Sulayman for helping to carry out this work. We also acknowledge Drs. Bryan Batch, Donna Washington, and Sarah Wilson for guidance on initial conceptualizations. We are especially grateful to the veterans and employee participants.

The views, opinions, and content of this manuscript are those of the authors and do not necessarily reflect the views, opinions, or policies of the Department of Veterans Affairs or the United States Government.

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.pmedr.2025.103224.

Appendix A. Supplementary data

Supplementary data 1

Employee and veteran interview guides.

mmc1.docx (26.4KB, docx)

Data availability

The data that has been used is confidential.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary data 1

Employee and veteran interview guides.

mmc1.docx (26.4KB, docx)

Data Availability Statement

The data that has been used is confidential.

Articles from Preventive Medicine Reports are provided here courtesy of Elsevier

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