Chef Lars Kronmark teaches veterans how to remove the skin of a fish; part of a four-day “boot camp” at Napa’s Culinary Institute of America where injured veterans and their spouses learn healthy cooking tips. (Mina Kim/KQED)

In a stainless-steel teaching kitchen deep within the old stone walls of the elite Culinary Institute of America in Napa Valley, acclaimed chef Lars Kronmark pulls a piece of fat from the cavity of a raw, whole chicken.

“A big chunk of fat like that, it doesn’t really hurt to leave it in there,” Kronmark said. “But in the end of the day, that’s still going to be too much fat.”

It looks like a standard cooking class. But this is an unusual class for an unusual group of students. It’s a healthy cooking “boot camp” designed for wounded veterans of the Iraq and Afghanistan wars with a goal of helping veterans connect with each other and learn to eat healthier.

Six military veterans and their spouses dressed in white chef’s coats and hats watch Kronmark closely. His healthy cooking techniques are welcome tips to the group of 12, including veteran James McQuoid, who lives with post-traumatic stress disorder.

“I’m of the larger variety,” McQuoid said. “A couple years ago, I didn’t care about my health. I was very reclusive and what not, but through therapy and stuff I’ve come to realize — I’ve got a younger child — I want to be around a bit longer, and I’m really not helping myself at all.”

A healthy dinner is served at Napa’s Culinary Institute of America healthy-cooking boot camp for injured veterans. (Mina Kim/KQED)

Federal officials estimate more than 70 percent of the veterans receiving care in the VA are overweight or obese. McQuoid’s doctor recommended he get more omega-3 fatty acids by eating fish instead of fatty meats.

“But I didn’t know how to cook fish,” McQuoid said. “After being here though, I can cook fish!”

The four-day boot camp is a program of the Wounded Warrior Project, a nonprofit that serves injured veterans transitioning to civilian life. The camp’s days begin with lectures on subjects like the physiology of taste and end with vets and their partners preparing dishes for dinner. Today’s menu includes roast chicken with lemon and rosemary, Baja fish tacos, and pork loin cooked in a pomegranate glaze.

Invisible Wounds

Yet, the program is playing a much bigger role than helping veterans eat better. Julia Valentour, health and wellness coordinator at the Wounded Warrior Project’s San Diego office, said there’s a waiting list for the classes that often helps veterans break through the isolation they feel when they return from war.

“I don’t think people realize what [veterans] go through and how much they sacrifice for us,” Valentour said. “You’re not hearing about the war on TV everyday, so you tend to forget that it’s still going on.”

At one cooking station a young man in a wheelchair with prosthetic legs, quietly peels sweet potatoes. Another veteran purses his lips in concentration as he chops cilantro using only one hand. But for many of the veterans, their wounds are not visible.

Tiffany Rush-Green who flew in from Phoenix for the class with her husband Yancy Green, a Marine, said this is the first time she’s seen her husband smile in a long time.

“Finally we can do something together, and take our time and just be a team so we can find that common ground,” Rush-Green said. “I am not a veteran, so a lot of times I can’t relate to him on certain issues, but cooking I think we’re going to be able to relate to each other on.”

Yancy Green said his wife is happy because she won’t have to do all the cooking anymore.

“I have no more excuses after this week,” he said.

For Renee Hampton and her husband — who asked not to give his name because he’s on active duty — being here is a dream come true. Hampton said her husband learned to cook when he was five and always wanted to be a chef, but chemicals used in the war robbed him of his ability to smell and taste. Still, it hasn’t dampened his experience in the class.

“I absolutely love this,” he said. “Besides, all my life, I’ve always wanted one of these [chef] jackets, and now I get one.”

For Culinary Institute chef Kronmark, the service members humble him in ways he hasn’t felt before.

“Makes you remember how lucky you are,” Kronmark said. “It’s really amazing.”

The next class is scheduled for May, and will be for spouses or caregivers of veterans.

Listen to Mina Kim’s story:

One in ten California veterans lack health insurance. (Robert Wood Johnson Foundation)

Ten percent of California veterans don’t have health insurance or don’t use Veterans Affairs (V.A.) care. That’s just slightly below the 10.3 percent rate among veterans around the country.

That’s according to a report by the Urban Institute. Co-author Jennifer Haley says there are 108,000 uninsured vets in the state, second only to the number in Texas.

“In our study someone is uninsured if they don’t have any of the types of insurance coverage you’d think of for general population and they also don’t report using V.A. care,” says Haley.

Haley used data from the 2010 American Community Survey to look at the rates among non-elderly vets, ages 19-64. She says disproportionate numbers of the uninsured were also unemployed and unmarried.

All of them reported big gaps in accessing health services compared to their insured counterparts. 41.2 percent of the uninsured reported unmet medical needs in the past 12 months as opposed to 12.7 percent of vets with insurance. And 33.7 percent of vets without health insurance said they were delaying care due to cost, compared to 8.4 percent of those with insurance.

Amy Fairweather director of policy with the San Francisco veterans advocacy group Swords to Plowshares says people often incorrectly assume that veterans automatically have health insurance through the V.A.

“They have to prove eligibility,” she says. Certain service distinctions automatically qualify you, she says, as does having a service connected illness. There is also a poverty means test, and certain treatments require co-pays.

Fairweather says because veterans are overrepresented in the homeless population in San Francisco “it comes as no surprise that there are so many veterans who are completely uninsured… except for the really community based system of care which is overburdened and can’t meet everyones needs.”

Still, she is quick to point out that for those who do have access in Northern California, the VA hospitals are excellent and are often connected with first class teaching hospitals.

“They’re very good with PTSD,” Fairweather says. “They’re very good with Agent Orange for older veterans, because that’s been their area of expertise. They obviously have to catch up with women and some other things.”

But she says it can be difficult to get in the door. Fairweather says the Oakland Veterans Benefit Administration, which determines eligibility has 34,000 claims backlogged.

“Claims are taking a year to two years for the initial walk through,” she says. “A lot of the initial decisions are appealable so that takes going through the system again.”

But the Urban Institute report did find that in California – and around the country – veterans are uninsured at lower rates than the general population. Among the non-elderly, about 18 percent of the general population was without insurance in 2010.

As with the general figure, where veterans live does seems to play a role in insurance status. The report found uninsurance rates among veterans fluctuated across states, from 4.3 percent in Massachusetts to 17.3 percent in Montana.

The Urban Institute’s Jennifer Haley says they were interested in what caused the state variation, and tried controlling for factors like differences in veterans’ incomes.

“But even when we controlled for that, the state differences didn’t go away,” she says. “It could be due of Medicaid enrollment differences or other state policy differences but we didn’t look in depth at that.”

The study was funded by the Robert Wood Johnson Foundation.

Soldiers on patrol in Iraq. (Photo: U.S. Army)

In a final decision five years in the making, a federal appeals court in San Francisco ruled Monday that the courts lack jurisdiction to order changes in the way the Veterans Administration handles mental health claims.

As the San Francisco Chronicle reports:

Two veterans groups said in a 2007 lawsuit that the VA had made mental health care virtually unavailable to thousands of discharged soldiers through perfunctory exams, long waits for referrals and treatment, and a prolonged medical benefits process in which vets can’t hire lawyers.

At a trial in 2008, Department of Veterans Affairs documents showed that the system took an average of 4.4 years to review veterans’ health care claims, that more than 1,400 veterans who had been denied coverage died in one six-month period while their appeals were pending, and that 18 veterans per day were committing suicide, much higher than the rate among the general population.

The District Court which heard the case in 2008 ruled that the legal remedies to the veterans’ complaints lay with Congress or the Department of Veterans Affairs — and not the courts. Last year a three judge panel overturned the District Court ruling. The Obama Administration requested the full Ninth Circuit Court consider the question, and yesterday’s decision confirmed the original District Court finding.

In a press release today, veterans groups expressed frustration with the decision:

Sandy Cook, the Vice-Chair for Plaintiff Veterans United for Truth (VUFT), remarked: “The message that this decision sends to the VA is that it can continue its unconstitutional practices unchecked by the power of the Courts. It would not be an exaggeration to call it a carte blanche approval for the VA to continue to mishandle, mistreat, and stiff our veterans.”

Bob Handy, the President of VUFT, added: “I should never underestimate the ability of our Courts to weave some rationale that leaves veterans out in the cold or on the street, homeless and destitute, without any recourse. It is no wonder that the suicide rate is so high.”

[Veterans for Common Sense] Executive Director, Patrick Bellon, said “I was always taught our Constitution trumps statutes and that our Courts were our last bastions to preserve our liberties; today, that promise has proved hollow, and all I hear is the continuing echoes of men and woman in distress. We should all feel their pain. This day will be remembered as the day our country turned its back on our veterans. VCS vows to fight this heartbreaking decision all the way to the end, because 18 of our veterans commit suicide every day.”

In April the VA announced plans to add 1,600 mental health clinicians to veterans hospitals across the country to help meet the growing need for mental health care, especially among veterans returning from service in Iraq and Afghanistan.

The week after the VA’s announcement, its own Inspector General issued a lengthy report finding that too many veterans were waiting too long for mental health care. Worse, the report found that the VA did not have a “reliable and accurate method of determining whether they are providing patients timely access to mental health services.” The Inspector General found just over half of new patients waited 50 days to be evaluated. VA rules require a full mental health evaluation for new patients in 14 days. About a third of patients then had longer than required waits to begin treatment.

Writing for the majority in yesterday’s 10-1 decision, Judge Jay Bybee acknowledged the merits of the veterans’ case:

VCS’s complaint sounds a plaintive cry for help, but it has been misdirected to us. As much as we may wish for expeditious improvement in the way the VA handles mental health care and service-related disability compensation, we cannot exceed our jurisdiction to accomplish it. … Such responsibilities are left to Congress and the Executive.

Veterans with PTSD are more likely than other vets to be prescribed opioid drugs for pain relief. (Photo: Jupiter Images)

Across the country, there’s been a greater understanding of treating pain. The prescription of opioid pain relievers–drugs like codeine, vicodin or morphine–has nearly doubled since 1994. But at the same time, prescription opioid abuse, overdose and death has also increased dramatically. The same trends are true for veterans of the Iraq and Afghanistan wars. Today, due to medical advances and improvements in combat protective gear, higher numbers of veterans of these wars are surviving injuries. But once home, they continue to suffer both pain and mental health problems. They are often prescribed opioid pain relievers.

But little has been known about mental health disorders and the prescribing of opioids to veterans. Researchers at the San Francisco Veterans Affairs Medical Center and UCSF set out to address this question and found that veterans with mental health problems were more likely to be prescribed opioid drugs than veterans without mental health issues.

The study, published Tuesday in the Journal of the American Medical Association, reviewed information from more than 140,000 Iraq and Afghanistan war veterans who were diagnosed with pain. Veterans without mental health problems were prescribed opioids much less frequently–about 6.5 percent of them received these prescriptions. That rate went up to 11.7 percent in veterans with a mental health diagnosis. And the rate was highest–17.8 percent–for veterans with Post-Traumatic Stress Disorder (PTSD).

The study also showed that all veterans that were prescribed opioids had a higher risk of misusing their prescription opioid by either over-dosing, having drug-related accidents, hurting oneself, or other things that would cause them to end up in the Emergency Room. That risk was the greatest among those with PTSD.

Lead author Karen Seal is a physician at the San Francisco Veterans Affairs Medical Center and a professor at UCSF. She says the study results are troubling. ”The message to me is to keep redoubling our efforts to really have conversations with patients about these risks, and really provide them alternatives to just taking Vicodin or oxycodone or morphine, which has become very, very common in our society.”

Seal says there were clear patterns in the data showing that Veterans Affairs (VA) patients with PTSD were more at risk for being on higher doses of opioids, and for longer periods of time. PTSD patients also had a higher risk of being prescribed two or more opioids simultaneously, and were more likely to get early refills on medications. She says getting early refills is a good indication that veterans may be abusing drugs by taking more than prescribed.

Seal says the VA often offers alternatives to opioid pain medication first, such as anti-inflammatory drugs, physical therapy, complementary alternative medicine, and various relaxation techniques. She says in her own practice, she’s found that when she approaches her patients about alternatives to opioid prescriptions, many patients say they would rather avoid the opioids and try these alternative therapies first.

“They particularly like going to physical therapy,” Seal said. “And actually trying — usually for the first time — modalities like acupuncture, chiropractory, relaxation, and even in some case psychotherapy that’s really meant to address their pain and PTSD, or other mental health problems, simultaneously.”

But Seal cautions that these alternative methods don’t always work. Some patients require opioid medication to relieve their pain. “In those cases you would still prescribe [opioids] to relieve pain and suffering, but you would do so in a way that you are assessing for risk, and you are monitoring their use of the medication.”

In the study, the authors note that the VA has guidelines that “urge caution in opioid prescribing” in people with substance abuse issues.

The Department of Veterans Affairs issued a written statement in response to the study saying it “agrees with the recommendation that VA continue to build upon its current approach to treating patients who have both pain and PTSD. This includes expanding Patient Aligned Care Teams (PACTs) that align primary care physicians with nurses, mental health providers, pharmacists and social workers. VA is committed to ensuring Veterans receive the quality care and benefits they have earned.”

Post Traumatic Stress Disorder is a major issue for female soldiers returning from the wars in Iraq and Afghanistan. (Chris Hondros: Getty Images)

The number of women in the military has doubled in the past decade. According to the Pentagon, about 10 percent of the 2.2 million troops who served in Iraq and Afghanistan have been women.

These women are more likely to be in the line of fire than those serving in previous wars — and that means they’re also at a higher risk of having depression, Post-Traumatic Stress Disorder (PTSD) and other mental health problems. Researchers at the University of California San Francisco and the San Francisco VA Medical Center (SFVAMC) wanted to see if gender played a role in mental health outcomes after soldiers were exposed to combat-related trauma. In a recent study, researchers looked at 7,251 veteran responses to different kinds of combat exposure: witnessing killing, sexual trauma, killing in war, and injury. They found that PTSD rates are the same among male and female vets of the Afghanistan and Iraq wars, with about 18 percent of both groups screening positive for the disorder.

While both male and female vets had equal chances of having PTSD after exposure to killing, sexual trauma, or witnessing killing, women vets who were injured were more likely to have PTSD than men.

The study also found that while female veterans were more likely to suffer from depression, their male counterparts were more likely to abuse alcohol.

Lead author Shira Maguen, a psychologist at SFVAMC and an assistant professor of psychiatry at UCSF, said the study suggests that doctors should get a detailed assessment of specific traumatic combat experiences because “not all types of combat may be equally experienced by men and women after they return from deployment.”

Though men and women had the same rates of PTSD due to sexual trauma, 12 percent of women actually reported experiencing sexual trauma, compared to less than one percent of men. Previous studies on female veterans show that those with a history of sexual trauma are about eight times more likely to suffer from PTSD than other female veterans.

Still, what’s surprising, said Maguen, is that there are more similarities than differences between male and female PTSD outcomes. She said the the VA needs to do more research on women’s health issues, but adds that they’re doing an “excellent” job adding women’s clinics for this growing population of veterans.

“At the San Francisco VA we have a one-stop-shop model where a woman veteran can come in and get medical care and mental health care and social work all in one visit. These are particular settings where women can really be evaluated. And if we have studies like this informing us what the highest risk factors are, we can really do a better job of assessing women, and hopefully that will lead to better treatment.”

The study was supported by the Department of Veterans Affairs, and was published electronically in the Journal of Psychiatric Research.