Last updated
CREW: Carbohydrate Reduction Empowering Wellness (formerly Therapeutic Carbohydrate Reduction (TCR) Aspire)
Share PrintVeterans with suboptimal cardiometabolic health face numerous challenges when trying to lose weight and control blood sugar and blood pressure. CREW is a 16-week group program that uses weekly goal setting and whole health coaching to support Veterans with Type 2 Diabetes and other metabolic health conditions. Veterans in CREW work to modify habits related to comprehensive lifestyle behaviors resulting in improved cardiometabolic health markers, weight loss, and deprescribing of medications. CREW uses a stop light approach to nutrition that allows Veterans to reduce their carbohydrate intake gradually and safely, while working with a pharmacist as needed to quickly adjust medications related to hypoglycemia and hypotension. CREW is a patient centered approach to controlling and reversing type two diabetes, insulin resistance, obesity, and other cardiometabolic chronic illness.
Origin:
January 2022, Charles George Department of Veterans Affairs Medical Center (Asheville)
Adoptions:
1 successful, 1 in-progress
Awards and Recognition:
VHA Shark Tank Winner
Partners:
Patient Centered Care and Cultural Transformation
Recent Updates
Overview
Problem
Our country is facing a metabolic health crisis, with rates of diabetes, fatty liver, hypertension, and obesity overtaking our population. Veterans are particularly at risk with rates of diabetes twice that of the broader population. Well over three fifths of all Veterans served in the VAHCS are already diagnosed with diabetes or present with cardiometabolic
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Our country is facing a metabolic health crisis, with rates of diabetes, fatty liver, hypertension, and obesity overtaking our population. Veterans are particularly at risk with rates of diabetes twice that of the broader population. Well over three fifths of all Veterans served in the VAHCS are already diagnosed with diabetes or present with cardiometabolic markers that make it likely they have diabetes or pre-diabetes. Additionally, our most vulnerable and historically underserved Veterans (racial and ethnic minorities, women, LGBTQ+, low-income) continue to have rates of diabetes that outpace their peers and stark health disparities in HEDIS metrics related to cardiometabolic health outcomes.
Veterans seeking to improve their cardiometabolic health and reduce their body weight face numerous barriers to achieving their goals. Insulin treatment for diabetes results in weight gain for the majority of users, while insulin resistance reduces the effectiveness of traditional calorie restriction. Indeed many of the Veterans we serve are opting to pursue risky fad diets while others have given up on comprehensive lifestyle interventions due to disbelief in their effectiveness.
CREW seeks to provide a safe and effective way for Veterans to gradually reduce their carbohydrate intake and increase their physical activity. In addition to improvements in health behaviors, CREW seeks to support Veterans in improving cardiometabolic health outcomes and reducing body weight. See more
Veterans seeking to improve their cardiometabolic health and reduce their body weight face numerous barriers to achieving their goals. Insulin treatment for diabetes results in weight gain for the majority of users, while insulin resistance reduces the effectiveness of traditional calorie restriction. Indeed many of the Veterans we serve are opting to pursue risky fad diets while others have given up on comprehensive lifestyle interventions due to disbelief in their effectiveness.
CREW seeks to provide a safe and effective way for Veterans to gradually reduce their carbohydrate intake and increase their physical activity. In addition to improvements in health behaviors, CREW seeks to support Veterans in improving cardiometabolic health outcomes and reducing body weight. See more
Images
VA national prevalence of diagnosed or likely diabetes and pre-diabetes, created by Amy Thompto.
BMI ranges for Veterans with Diabetes Served by the VAHCS in FY 23' created by Amy Thompto
Solution
CREW is a whole health informed, easy to follow, comprehensive lifestyle intervention program for Veterans with excess weight, type 2 diabetes, or other cardiometabolic health conditions. This 16-week program can be offered in person or virtually and provides support to Veterans as they work to improve their diet, increase physical activity, and address glob
...
CREW is a whole health informed, easy to follow, comprehensive lifestyle intervention program for Veterans with excess weight, type 2 diabetes, or other cardiometabolic health conditions. This 16-week program can be offered in person or virtually and provides support to Veterans as they work to improve their diet, increase physical activity, and address global health behavior change. CREW is facilitated by a Whole Health Coach trained professional who supports Veterans in setting weekly SMART goals, celebrating successes, and over-coming barriers to change. A Registered Dietitian Nutritionist provides medical nutrition therapy guiding Veterans in safely reducing carbohydrate intake to a low or very-low carbohydrate diet. A Clinical Pharmacist Practitioner (CPP) educates Veterans on medication changes, hypoglycemia treatment, and other potential side-effects of a lower carbohydrate diet. The CPP is available to work with Veterans individually on an as needed basis for further education and medication management.
Dietary changes are guided by use of a stop light system with green foods very-low to free of carbohydrates, yellow foods composed of nutritionally dense carbohydrate rich foods, and red foods composed of nutrient poor and highly processed carbohydrate rich foods. All participants in CREW complete a thorough set of cardiometabolic labs (HbA1C, fasting blood glucose, serum creatinine/eGFR panel, liver function panel, C-Peptide) prior to enrollment and at the end of their four month participation.
Tools:
- CREW Workbook**
- CREW Food & Activity Log
- CREW Stop Light Food Identification Cards
- CREW Standard Operating Procedures
** CREW manual has been augmented from the VA Clinical Research Center’s Year Long Aspire Program. See more
Dietary changes are guided by use of a stop light system with green foods very-low to free of carbohydrates, yellow foods composed of nutritionally dense carbohydrate rich foods, and red foods composed of nutrient poor and highly processed carbohydrate rich foods. All participants in CREW complete a thorough set of cardiometabolic labs (HbA1C, fasting blood glucose, serum creatinine/eGFR panel, liver function panel, C-Peptide) prior to enrollment and at the end of their four month participation.
Tools:
- CREW Workbook**
- CREW Food & Activity Log
- CREW Stop Light Food Identification Cards
- CREW Standard Operating Procedures
** CREW manual has been augmented from the VA Clinical Research Center’s Year Long Aspire Program. See more
- ADA low carb and very low carb booklet American Diabetes Association Low Carbohydrate Education & Guidance
- Standard Operating Procedures SOP for TCR-Aspire
- Guide for sites and facilitators interested in delivering CREW CREW Introduction
- Orientation + 16 week interactive workbook for Veterans participating in CREW CREW Veteran Workbook
Files
Results
Type 2 diabetes has historically been considered an incurable disease. Research now demonstrates that a carbohydrate reduced diet can reverse type 2 diabetes while also supporting weight loss and overall improvements to cardiometabolic health.
CREW supports Veterans on their path to reversing diabetes. On average, the first cohort of 13 graduates lost an ... Type 2 diabetes has historically been considered an incurable disease. Research now demonstrates that a carbohydrate reduced diet can reverse type 2 diabetes while also supporting weight loss and overall improvements to cardiometabolic health.
CREW supports Veterans on their path to reversing diabetes. On average, the first cohort of 13 graduates lost an average of 15 pounds, reduced HgbA1C by 0.71%, reduced triglycerides by 31 mg/dl, and reduced liver function tests. Of the 13 graduates, 8 were able to de-escalate medications. The current cohort has lost an average of 5% body weight at week 8 with 9 out of 12 participants meeting a 5% weight loss target.
CREW participants report higher levels of self-esteem and overall quality of life. Veterans report feeling supported and accomplished, noting increased confidence in their ability to make and maintain healthy changes to their nutrition, physical activity, and health behaviors.
Traditional weight management and metabolic health education providers are at high risk for burnout due to limited participant success. CREW facilitators are re-energized by the joy expressed by participants, the consistent lifestyle changes, and the clear weight and laboratory benefits. See more
CREW supports Veterans on their path to reversing diabetes. On average, the first cohort of 13 graduates lost an ... Type 2 diabetes has historically been considered an incurable disease. Research now demonstrates that a carbohydrate reduced diet can reverse type 2 diabetes while also supporting weight loss and overall improvements to cardiometabolic health.
CREW supports Veterans on their path to reversing diabetes. On average, the first cohort of 13 graduates lost an average of 15 pounds, reduced HgbA1C by 0.71%, reduced triglycerides by 31 mg/dl, and reduced liver function tests. Of the 13 graduates, 8 were able to de-escalate medications. The current cohort has lost an average of 5% body weight at week 8 with 9 out of 12 participants meeting a 5% weight loss target.
CREW participants report higher levels of self-esteem and overall quality of life. Veterans report feeling supported and accomplished, noting increased confidence in their ability to make and maintain healthy changes to their nutrition, physical activity, and health behaviors.
Traditional weight management and metabolic health education providers are at high risk for burnout due to limited participant success. CREW facilitators are re-energized by the joy expressed by participants, the consistent lifestyle changes, and the clear weight and laboratory benefits. See more
Images
TCR-Aspire participant quotes
TCR-Aspire Cohort 1 poster presentation by PharmDs Murphy and Quinn
- Female Veteran shared her story of TCR-Aspire participation. Veteran Review of TCR-ASPIRE
Files
Metrics
- Cardiometabolic Laboratory Outcomes Cohort 1 (see image below)
- Average Weight Loss Cohort 1 (see image below)
- Medication Interventions Cohort 1 (see image below)
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Multimedia
Images
Change in Cardiometabolic Laboratory Values from Baseline to Post-Program By PharmD Kaitlyn Quinn
Average Weight Loss from Baseline to Week 16 by PharmD Kaitlyn Quinn
Pertinent Medication Interventions Implement During the TCR Aspire Program by CPP Kaitlyn Quinn
Implementation
Timeline
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Months 1-2
Train staff in CREW approach and support team in recruiting participants; gathering resources. -
Months 3-7
Observing CREW Virtually with ongoing coaching from innovation team. -
Months 5-9
Begin local CREW program w/ support and mentoring from Innovation team. -
Months 9-10
Innovation team supports facility CREW team in analyzing outcomes and exploring opportunities for process improvement and future outcome publication.
Departments
- Pharmacy
- MOVE! weight management
- Whole health
- Nutrition, food, and dietary
Core Resources
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Files
- Example of work distribution amongst an additional team. Role Delineation
Optional Resources
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Support Resources
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PEOPLE |
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Risks and mitigations
| Risk | Mitigation |
|---|---|
| Staffing demands | Our facility was able to offset staffing concerns by shifting resources typically provided to MOVE! and PACT PharmD. |
Contact
Comment
Comments and replies are disabled for retired innovations and non-VA users.
Email amy.thompto@va.gov with questions about this innovation.
About
Origin story
TCR-Aspire grew from the year-long Aspire program designed by the VA's Clinical Research Center in Ann Arbor Michigan. The WNCVAHCS has offered Aspire for eight years with a high degree of patient satisfaction and weight loss outcomes. The demand amongst Veterans for a low carbohydrate has grown over the past 3 years along with evidence and professional guid
...
TCR-Aspire grew from the year-long Aspire program designed by the VA's Clinical Research Center in Ann Arbor Michigan. The WNCVAHCS has offered Aspire for eight years with a high degree of patient satisfaction and weight loss outcomes. The demand amongst Veterans for a low carbohydrate has grown over the past 3 years along with evidence and professional guidelines supporting a therapeutic carbohydrate reduction nutritional approach to weight management for Veterans with Diabetes and other metabolic health conditions. Dr. Kendrick Murphy, CPP has long been a champion of TCR. Then MOVE! Coordinator, Amy Thompto RD/N, MS met with Dr. Murphy and others from the WNCVAHCS to discover a path to safely guiding Veterans with metabolic health concerns through a TCR nutritional approach. Through these conversations and knowledge sharing, the TCR-Aspire program was born. Veterans quickly and enthusiastically signed up for TCR-Aspire with new interest increasing daily such that TCR-Aspire does not have openings until May of 2024.
Original team
Kendrick Murphy
Clinical Pharmacy Practitioner
Loretta Ward
PTA and Whole Health Coach
Amy Thompto
Whole Health Coach and Registered Dietitian/Nutritionist
Kaitlyn Quinn
Pharmacy Resident, now PharmD
I'm assuming that this is not applicable for Type 1 Diabetics?
The keto diet could cause low blood pressure, kidney stones, constipation, nutrient deficiencies and an increased risk of heart disease. Strict diets like keto could also cause social isolation or disordered eating. Keto is not safe for those with any conditions involving their pancreas, liver, thyroid or gallbladder.
Someone new to the keto diet can also experience what’s called the “keto flu” with symptoms like upset stomach, dizziness, decreased energy, and mood swings caused by your body adapting to ketosis.
Thank you for your response. It's important to note that CREW is not a ketogenic diet, rather, it is a path that supports Veterans in identifying the carbohydrates they eat and then improve and/or reduce their carbohydrates. The majority of participants, so far 80%, have successfully achieved their goals while eating around 30grams of carbohydrates a meal and up to 15grams a snack for a sum total of around 100grams of carbohydrates a day. The gradual and individualized approach CREW takes, supports Veterans in finding a new nutritional normal that is sustainable and nutrient rich.