'Let Me Figure Out What Works For Me': Managing Women Veterans’ Cardiovascular Risk

Cardiovascular disease (CVD) remains the leading cause of death among women in the United States-and among women Veterans, the risk is even more pronounced. 80% of chronic conditions can be prevented by adopting healthy lifestyle improvements like quitting smoking, improving diet, increasing physical activity, and improving sleep, and these behaviors are widely recommended by the American Heart Association, the Centers for Disease Control and Prevention, and the VA National Center for Health Promotion and Disease Prevention. While sustaining these changes is difficult for most people under the best of circumstances, women Veterans face a particularly complex set of challenges.

Previous research has noted that women Veterans often have co-occurring mental health conditions, like PTSD and anxiety, which can make it harder to implement these changes. They also contend with caregiving responsibilities, barriers to accessing available facilities, such as a lack of transportation, and preference for female-specific programs that are not always available. Designing interventions that work for this population requires understanding what gets in the way, and what helps.

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Researchers from the Center for Healthcare Innovation, Implementation, and Policy (CSHIIP) in the VA Greater Los Angeles Healthcare System conducted this qualitative study as part of a larger quality improvement initiative called the CV Toolkit, implemented at five geographically diverse VA primary care sites from June 2017 to March 2020. Tools in the CV Toolkit included a brief cardiovascular risk screening tool that patients completed at primary care check-in, a matching template for providers to document risk discussions in the electronic health record, and a site-specific menu of health promotion and behavior change programs to support same-visit referrals.

Among 1,609 women Veterans exposed to at least one component of the CV Toolkit, 253 completed a mailed survey and 48 agreed to a 30-minute telephone interview. Interview participants did not differ significantly in age, race, or educational background from survey completers who were not interviewed. The group reported high rates of depression (61%), high blood pressure (54%), high cholesterol (44%), and obesity or overweight (72%). Most (91%) had at least one major cardiovascular risk factor.

Semi-structured interviews explored:

• What types of lifestyle changes women Veterans wanted to make
• What barriers they encountered
• What experiences and strategies helped them succeed

Interviews were recorded, professionally transcribed, and analyzed to identify common themes.

Most of the interviewees reported attempting more than one health behavior change. The most common attempts involved:

• Better diet (75%)
• More exercise (75%)
• Better sleep
• Better mental health management
• Taking medications as prescribed
• Quitting smoking

More than a third (35%) of participants used a formal program to support behavior change-and of those, more than half participated in MOVE!, VA's sponsored weight management program.

Barriers to Lifestyle Change

Women Veterans described a wide range of barriers that complicated their efforts:

• Physical health conditions: Musculoskeletal conditions, pain, sleep disturbances, gastrointestinal issues, polycystic ovary syndrome, and conditions related to aging (such as osteoporosis) made it difficult to increase physical activity or change diets. For some, being overweight was itself a barrier, reducing energy and making exercise harder:
  • "You put on more weight, and it gets harder to exercise because you're carrying more weight around, and your knees hurt, and your back hurts."
• Mental health challenges: Anxiety, depression, PTSD, and general stress affected motivation and, in some cases, drove behaviors like smoking that provided temporary relief from stress:
  • "I deal with major depression, and so I have other things healthwise that I'm dealing with that makes [lifestyle change] difficult."
• Access barriers: Transportation difficulties, long distances to facilities, busy work schedules, and caregiving responsibilities limited the time and means available for exercise, nutrition classes, and professional dietary guidance:
  • "I'm the caregiver for my husband… I just have to find time for myself, and sometimes that's hard to do."
• Insufficient information: Some women were uncertain which diet to follow, or how to implement specific changes safely alongside their other health conditions.
• The COVID-19 pandemic: Gym closures, class cancellations, grocery shortages, and reduced access to mental health services disrupted many women's plans. A few, however, found that the lockdown period provided unexpected time for self-care.
• Personal attributes: Women sometimes attributed difficulties to their own tendencies-procrastination, negative thinking, or lack of discipline-often placing full responsibility on themselves even when structural factors were clearly at play. One woman Veteran compared her mental health practices as a "toolbox":
  • "Sometimes I remember to open the toolbox. Sometimes I forget."

Successful Strategies

Despite these challenges, women Veterans were remarkably self-aware about what would and would not work for them. The most common strategies they identified were:

• An incremental approach: Rather than attempting big, immediate changes, women modified their goals to fit their lives: taking the stairs instead of the elevator, eating healthier foods without eliminating favorites, or scheduling a massage when other stress-reducing options were unavailable. Women adopted a balanced, non-restrictive approach to eating rather than cycles of deprivation:
  • "I took that mentality of let's make it my own, let me figure out what works for me and then I'm more likely gonna stick with it."
• Achievable goals: Women set smaller targets-shorter exercise intervals, fewer steps, or maintaining rather than losing weight-and accepted that their limits might differ from day to day without treating this as failure:
  • "Maybe I have bad days, and during my bad days, you know, I still walk, but shorter… I don't push it to the limit, because I know my limit."
• Targeted provider recommendations: Specific, personalized advice from providers-dietary substitutions, fitness app suggestions, tips on how to quit smoking, or anti-inflammatory foods-was valued highly. Women appreciated when providers took time to tailor recommendations to their individual barriers and preferences.
  • "[My provider] gave me a folder [with] some recommendations, especially about eating protein…It was really helpful. It kind of changed my lifestyle…she really took the time to educate me."
• Self-education : Women who researched healthy eating, exercise regimens, or symptom management often described themselves as self-starters, inclined to take initiative with their own health.
• Compelling motivation: Having a strong personal reason to change-improving health for a grandchild, a family history of CVD, wanting to fit into old clothes-helped women stay committed. The motivation didn't have to be medical; it just had to matter:
  • "I had a two-year-old granddaughter and a year-old grandson, and…he didn't like to snuggle because I smelled [like smoke]…so I decided that's it, I'm done, and I have not smoked since."
• Mindfulness and self-monitoring: Fitness trackers, journaling, monitoring sleep or blood pressure, and taking time for self-reflection provided positive reinforcement and helped women stay on track.

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In most cases, women Veterans knew what they needed to do to lower their CVD risk-and their responses suggest both that sustaining healthy behaviors is challenging and that a one-size-fits-all approach is insufficient for their complex needs. Providers can bridge the gap between knowledge and action by harnessing the self-awareness Veterans already possess and translating general recommendations into manageable steps tailored to each person's circumstances.

Key takeaways for VA providers and program planners include:

• The use of motivational interviewing techniques to help women Veterans clarify their goals and build confidence.
• Specific, Measurable, Action-oriented, Reliable, and Time-limited (SMART) goal-setting, rather than generic lifestyle prescriptions.
• Personalized health advice that accounts for physical limitations, mental health status, caregiving demands, and preferences.
• Self-monitoring tools such as fitness trackers or mobile weight management apps, which have shown positive results in Veteran populations.
• The recognition that structural barriers such transportation, food insecurity, or caregiving may require solutions beyond individual counseling.

For women Veterans with limited motivation or access to specialized programs, primary care providers may be the most accessible point of contact. Strong provider support, including access to current CVD prevention guidelines and vetted educational materials, is essential for translating research into health gains.

Kimberly Clair, PhD, MSPH, is a Health Science Specialist with the Center for Health Innovation, Implementation, and Policy at the Greater Los Angeles VA.

Study Publication

Clair K, Fletcher EH, Oishi A, et al. "'It's Just a Matter of Doing It': Women Veterans' Experiences with Changing Behavior for Cardiovascular Risk Reduction."Journal of General Internal Medicine. April 20, 2026; published online.

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The views expressed in this publication are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.