The aim of the current study is to understand the health trajectory of female veterans who participated in a VHA sponsored weight management program and explore possible barriers to sustained weight loss and improved metabolic functioning over time. Obesity is a major health concern for discharged service members and women veterans in particular are faced with an increasing prevalence of obesity at a younger age with obese ethnic minorities posing the greatest health risk over time. The current study measured body mass index (BMI), triglycerides, and total cholesterol in female participants enrolled in the MOVE! ® Weight Management Program for Veterans at the Miami VAHS from 2005-2008 (N = 170). The sample was derived from an archival data set and participants were predominantly non-Hispanic Black (NHB) (n = 93, 54.7%), with a mean age of 48.26 (SD = 11.77) and BMI of 34.97 (SD = 6.61) at program entry. Medical information was gathered as part of routine primary care and participants were not asked to provide additional information. Multilevel modeling was utilized to measure change in BMI, triglycerides, and total cholesterol across seven time points before and after MOVE! ® participation. For the piecewise model, results showed a positive linear growth pattern in BMI prior to program enrollment, SE = .12, p < .001, and a negative linear pattern post-intervention, SE = .08, p = .05. For the continuous models, significant differences in triglycerides were observed between ethnic groups at program entry, but overall triglycerides did not significantly change over time. A significant negative linear effect was found for total cholesterol, SE = 1.08, p < .001. Age was found to be a significant negative predictor of triglycerides, SE = .003, p = .008, and total cholesterol, SE = .27, p = .003. VA user status, small sample size, and other extraneous lifestyle factors not directly measured in the current study may explain the lack of significant differences in BMI found between ethnic groups relative to literature on weight loss outcomes. Additionally, BMI in women may underestimate their total fat, which for the present study may explain why larger improvements in metabolic functioning were not observed. Future designs may consider measuring waist circumference to understand the complex relationship between total fat distribution and markers for poor health and utilizing a tailored approach to weight management.

This dissertation examines policy changes and incentive programs in kidney transplantation in the United States (U.S.) and their effects on adult obesity, on provision of care, and on patients’ overall welfare. This work uses rigorous identification strategies to quantify the impact, to investigate effectiveness, and to identify potential unintended consequences related to the institution environment in transplantation. Among others, findings are informative of a general understanding of weight loss behavior. Results also provide understanding of trade-offs—inherent in policy making—in this environment, which further affect access to transplantation. The first essay investigates effectiveness of weight loss incentives in transplantation. “How to incentivize weight loss?” is one of the central questions in health economics research. An example with high stakes is in the lifesaving treatment of organ transplantation, where transplantation centers use differential BMI requirement as eligibility for transplantation. This chapter investigates the effects of BMI requirements on probability of weight loss. Using a difference-in-difference framework correcting for sample selection bias for deceased donor transplant recipients, I find that having an explicit BMI requirement causes a 16.1 percentage point increase in the probability of weight loss. Weight loss is documented not only for overweight but also for severely and morbidly obese individuals. In addition, weight loss increases organ transplant survival for the severely and morbidly obese. The second essay evaluates the effects of the Centers for Medicare and Medicaid Services (CMS) Final Rule on transplantation on patient welfare. Effective on June 28, 2007, the CMS established a new accountability policy for transplant centers to improve patient quality services and to reduce re-transplantation rates. Nonetheless, the regulation could exacerbate the current organ shortage problem. This study uses variations across centers between 2002 and 2009, and finds evidence that the regulation leads to undesirable effects on provision of care. The estimated decrease in graft failures for low-performing centers is negated by a decline in access to transplantation, creating a tradeoff between quality and access in the provision of care. Results suggest a sizeable reduction of about 5 to 6 less transplants per 6-month period at low-performing centers on both patient survival and graft survival outcomes after the regulation. The estimated declines in volume do not translate into comparable increases in volume at high-performing centers. The last essays emphasizes the effect of the CMS conditions of participations (CoPs) for transplant centers on patients’ selection of transplant centers. I am concerned that the report cards published by the Scientific Registry of Transplant Recipients (SRTR) may impact the centers patients’ selection to be placed on the waiting list and the queuing of patients on a center’s waiting list. I construct a spatial data set of a patient’s (and referring physicians’) choice set between 2003 and 2010. Results from this less competitive model indicate that a center’s failure to meet the 1-year organ transplant survival outcomes decreases the probability that a patient will elect to be placed on a center’s waiting list versus those centers that are spatial proximate to that center. Distance traveled to a center is found to reduce probability of listing at a center, whereas the number of ECD transplants performed during any given year increase that propensity. The regulation effects are purged out in sorting equilibrium models which account for competitive interactions between centers. I find evidence for a strong congestion effect and demonstrate importance of center-level heterogeneity in predicting patient selection of centers. In summary, this dissertation shows importance of altering individual’s trade-offs in order to create behavior change, more specifically with policies trying to alt obesity. It further shows in the case of transplantation that the accountability policy established by the CMS mostly affects the supply side of the market with greater impacts on transplants volume and access to transplantation than it does on the demand for transplantation.

Weight loss programs for women are on the rise, including both face to face and online programs. However, current research is limited on the process measures and content which produce adherence and the largest outcomes. With obesity on the rise in the United States, it is important to understand out health coaches can strengthen their programs to better support the obese population in their weight loss journey. The purpose of this pilot study was to develop and test the acceptability of text message nudges among women participating in an online weight loss program; determine how dose may be associated with weight loss outcomes; and to test how goal setting text messaging nudges improve percent body weight loss among women participating in an online weight loss program. It was found that the implementation of text message nudges did not provide enough to continue to improve and extend the program to be more successful. However, qualitative data was recorded and found to provide helpful insight into what content was preferred by the participants.

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