About

Alyson Littman is a Research Professor in the Department of Epidemiology at the University of Washington. She holds a PhD and an MPH from the University of Washington, obtained in 2003 and 2000 respectively. Her research focuses on clinical epidemiology, with key areas including physical activity, obesity, lower limb amputation, and access to care. She is based at the Department of Veterans Affairs within the Seattle Epidemiologic Research and Information Center and the Seattle-Denver Center for Innovation for Veteran Centered and Value-Driven Care. Dr. Littman's work includes conducting a national evaluation of access to care for rural Veterans and studying outcomes after toe amputation. She collaborates on several studies, including research on incentives for physical activity and weight loss, as well as examining associations between military service and health outcomes in the Millennium Cohort, a longitudinal study of active duty and Reserve/National Guard personnel.

Research topics

• Medicine
• Internal medicine
• Computer Science
• Artificial Intelligence
• Sociology
• Surgery
• Machine Learning
• Computer Security
• Data Mining
• Demography
• Knowledge management
• Mathematics
• Clinical psychology
• Environmental health
• Psychiatry
• Data science
• Statistics
• Gerontology

Selected publications

• Associations between social connection and gender identity among transgender and gender diverse U.S. veterans

  International Journal of Transgender Health · 2026-02-21

  articleSenior author
  PublisherDOI

• Understanding Patient Preferences Regarding Limb Salvage for Diabetic Foot Ulcers: A Discrete Choice Experiment

  2025-07-14

  preprintOpen access

  <p dir="ltr">Objective</p><p dir="ltr">Diabetic foot ulcers (DFUs) often lead to amputations. Limb salvage aims to preserve the lower extremity, but the complexity of care and uncertainty of healing can delay patients’ return to normal activities. This study aimed to understand Veterans’ preferences regarding limb salvage for DFUs using a discrete choice experiment (DCE).</p><p dir="ltr">Research Design and Methods</p><p dir="ltr">A DCE was conducted with 98 Veterans with diabetes at the Baltimore VA Medical Center. Participants were presented with 10 choice sets involving different levels of post-recovery mobility, amputation levels, and future surgery risks. These attributes were developed through literature review and interviews. Data were analyzed using a multinomial logit model to estimate the utility of each attribute level and assess preference heterogeneity.</p><p dir="ltr">Results</p><p dir="ltr">The study population was older (mean age 69 years), Black (61%), and male (94%). 53% had a prior foot complication. Post-recovery mobility was the most important attribute (relative importance 53%), followed by amputation level (30%) and future surgery risk (18%). Veterans valued mobility highly, with significant utility differences between walking unaided and needing a wheelchair/scooter. They were willing to accept higher amputation levels to improve mobility.</p><p dir="ltr">Conclusions</p><p dir="ltr">Post-recovery mobility is a critical factor for Veterans with DFUs, outweighing concerns about amputation level and future surgical risks. It should be a focus of shared decision-making. The study is limited by its single-site setting and study population. Broader research is needed. Understanding patient preferences through DCE can inform more patient-centered approaches to DFU management, potentially improving outcomes and satisfaction.</p><p><br></p>

  PublisherOA PDFDOI

• Understanding Patient Preferences Regarding Limb Salvage for Diabetic Foot Ulcers: A Discrete Choice Experiment

  2025-07-03

  preprintOpen access

  <p dir="ltr">Objective</p><p dir="ltr">Diabetic foot ulcers (DFUs) often lead to amputations. Limb salvage aims to preserve the lower extremity, but the complexity of care and uncertainty of healing can delay patients’ return to normal activities. This study aimed to understand Veterans’ preferences regarding limb salvage for DFUs using a discrete choice experiment (DCE).</p><p dir="ltr">Research Design and Methods</p><p dir="ltr">A DCE was conducted with 98 Veterans with diabetes at the Baltimore VA Medical Center. Participants were presented with 10 choice sets involving different levels of post-recovery mobility, amputation levels, and future surgery risks. These attributes were developed through literature review and interviews. Data were analyzed using a multinomial logit model to estimate the utility of each attribute level and assess preference heterogeneity.</p><p dir="ltr">Results</p><p dir="ltr">The study population was older (mean age 69 years), Black (61%), and male (94%). 53% had a prior foot complication. Post-recovery mobility was the most important attribute (relative importance 53%), followed by amputation level (30%) and future surgery risk (18%). Veterans valued mobility highly, with significant utility differences between walking unaided and needing a wheelchair/scooter. They were willing to accept higher amputation levels to improve mobility.</p><p dir="ltr">Conclusions</p><p dir="ltr">Post-recovery mobility is a critical factor for Veterans with DFUs, outweighing concerns about amputation level and future surgical risks. It should be a focus of shared decision-making. The study is limited by its single-site setting and study population. Broader research is needed. Understanding patient preferences through DCE can inform more patient-centered approaches to DFU management, potentially improving outcomes and satisfaction.</p><p><br></p>

  PublisherOA PDFDOI

• Understanding Patient Preferences Regarding Limb Salvage for Diabetic Foot Ulcers: A Discrete Choice Experiment

  2025-07-03

  preprintOpen access

  <p dir="ltr">Objective</p><p dir="ltr">Diabetic foot ulcers (DFUs) often lead to amputations. Limb salvage aims to preserve the lower extremity, but the complexity of care and uncertainty of healing can delay patients’ return to normal activities. This study aimed to understand Veterans’ preferences regarding limb salvage for DFUs using a discrete choice experiment (DCE).</p><p dir="ltr">Research Design and Methods</p><p dir="ltr">A DCE was conducted with 98 Veterans with diabetes at the Baltimore VA Medical Center. Participants were presented with 10 choice sets involving different levels of post-recovery mobility, amputation levels, and future surgery risks. These attributes were developed through literature review and interviews. Data were analyzed using a multinomial logit model to estimate the utility of each attribute level and assess preference heterogeneity.</p><p dir="ltr">Results</p><p dir="ltr">The study population was older (mean age 69 years), Black (61%), and male (94%). 53% had a prior foot complication. Post-recovery mobility was the most important attribute (relative importance 53%), followed by amputation level (30%) and future surgery risk (18%). Veterans valued mobility highly, with significant utility differences between walking unaided and needing a wheelchair/scooter. They were willing to accept higher amputation levels to improve mobility.</p><p dir="ltr">Conclusions</p><p dir="ltr">Post-recovery mobility is a critical factor for Veterans with DFUs, outweighing concerns about amputation level and future surgical risks. It should be a focus of shared decision-making. The study is limited by its single-site setting and study population. Broader research is needed. Understanding patient preferences through DCE can inform more patient-centered approaches to DFU management, potentially improving outcomes and satisfaction.</p><p><br></p>

  PublisherDOI

• Understanding Patient Preferences Regarding Limb Salvage for Diabetic Foot Ulcers: A Discrete Choice Experiment

  Diabetes Care · 2025-07-03 · 6 citations

  articleOpen access

  OBJECTIVE: Diabetic foot ulcers (DFUs) often lead to amputations. Limb salvage aims to preserve the lower extremity, but the complexity of care and uncertainty of healing can delay patients' return to normal activities. This study aimed to understand military veterans' preferences regarding limb salvage for DFUs, using a discrete choice experiment (DCE). RESEARCH DESIGN AND METHODS: A DCE was conducted with 98 veterans with diabetes at the Baltimore Veterans Affairs Medical Center. Participants were presented with 10 choice sets involving different levels of postrecovery mobility, amputation levels, and future surgery risks. These attributes were developed through literature review and interviews. Data were analyzed using a multinomial logit model to estimate the utility of each attribute level and assess preference heterogeneity. RESULTS: The study population was older (mean age 69 years), Black (61%), and male (94%). Half (53%) had a prior foot complication. Postrecovery mobility was the most important attribute (relative importance 53%), followed by amputation level (30%) and future surgery risk (18%). Veterans valued mobility highly, with significant utility differences between walking unaided and needing a wheelchair or scooter. They were willing to accept higher amputation levels to improve mobility. CONCLUSIONS: Postrecovery mobility is a critical factor for veterans with DFUs, outweighing concerns about amputation level and future surgical risks. It should be a focus of shared decision-making. The study is limited by its single-site setting and study population. Broader research is needed. Understanding patient preferences through DCE can inform more patient-centered approaches to DFU management, potentially improving outcomes and satisfaction.

  PublisherOA PDFDOI

• The association between healthcare access and shingles vaccination among older adults in Virginia, United States

  PLoS ONE · 2025-04-15 · 3 citations

  articleOpen access

  INTRODUCTION: Shingles is a debilitating vaccine preventable disease that poses a health threat to older adults. However, the uptake of shingles vaccines remains low, and the factors contributing to the low uptake are not clearly understood. This study assessed the association between healthcare access and shingles vaccination among older adults, as well as the impact of COVID-19 pandemic on vaccine uptake. METHODS: This was a cross-sectional study among adults 50 + years in Virginia (n = 16,576) using data from the Behavioral Risk Factor Surveillance System (2018, 2019, and 2021). We calculated the prevalence of shingles vaccination by health insurance and access to primary health care provider (used as proxies for healthcare access) and in relation to the COVID-19 pandemic (pre vs during). Log binomial regression models were used to estimate prevalence ratios (PR), adjusting for confounders. RESULTS: Shingles vaccination was substantially higher among those with healthcare access compared to those without. Specifically, shingles vaccination was 35% among those with health insurance vs. 10% among those without (adjusted PR (aPR): 2.03, 95% CI 1.44, 2.86), and 36% among those with a primary healthcare provider vs 15% among those without (aPR: 1.99, 95% CI: 1.65-2.41). Finally, shingles vaccination was 41% during the COVID-19 pandemic vs. 30% before (aPR:1.26, 95% CI: 1.20-1.33). CONCLUSION: Individuals with health insurance and access to a primary healthcare provider were significantly more likely to receive the shingles vaccine compared to those without such access. Moreover, the prevalence of shingles vaccination during the pandemic period was substantially higher compared with shingles vaccination before the pandemic.

  PublisherDOI

• Non-affirmation minority stress, internalized transphobia, and subjective cognitive decline among transgender and gender diverse veterans aged 45 years and older

  Aging & Mental Health · 2024-04-03 · 2 citations

  articleSenior author

  OBJECTIVES: To examine the associations of two measures of minority stress, non-affirmation minority stress and internalized transphobia, with subjective cognitive decline (SCD) among transgender and gender diverse (TGD) veterans. METHOD: We administered a cross-sectional survey from September 2022 to July 2023 to TGD veterans. The final analytic sample included 3,152 TGD veterans aged ≥45 years. We used a generalized linear model with quasi-Poisson distribution to calculate prevalence ratios (PR) and 95% confidence intervals (CIs) measuring the relationship between non-affirmation minority stress and internalized transphobia and past-year SCD. RESULTS: = 857) reported SCD. Adjusted models revealed that TGD veterans who reported experiencing non-affirmation minority stress or internalized transphobia had greater risk of past-year SCD compared to those who did not report either stressor (aPR: 1.09, 95% CI: 1.04-1.15; aPR: 1.19, 95% CI: 1.12-1.27). CONCLUSION: Our findings demonstrate that proximal and distal processes of stigma are associated with SCD among TGD veterans and underscore the need for addressing multiple types of discrimination. Above all, these results indicate the lasting sequelae of transphobia and need for systemic changes to prioritize the safety and welfare of TGD people.

  PublisherDOI

• Assessing equity in the uptake of remote foot temperature monitoring in a large integrated US healthcare system

  PLoS ONE · 2024-04-01

  articleOpen access1st authorCorresponding

  OBJECTIVE: We assessed equity in the uptake of remote foot temperature monitoring (RTM) for amputation prevention throughout a large, integrated US healthcare system between 2019 and 2021, including comparisons across facilities and between patients enrolled and eligible patients not enrolled in RTM focusing on the Reach and Adoption dimensions of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. MATERIAL AND METHODS: To assess whether there was equitable use of RTM across facilities, we examined distributions of patient demographic, geographic, and facility characteristics across facility RTM use categories (e.g., no RTM use, and low, moderate, and high RTM use) among all eligible patients (n = 46,294). Second, to understand whether, among facilities using RTM, there was equitable enrollment of patients in RTM, we compared characteristics of patients enrolled in RTM (n = 1066) relative to a group of eligible patients not enrolled in RTM (n = 27,166) using logistic regression and including all covariates. RESULTS: RTM use increased substantially from an average of 11 patients per month to over 40 patients per month between 2019 and 2021. High-use RTM facilities had higher complexity and a lower ratio of patients per podiatrist but did not have consistent evidence of better footcare process measures. Among facilities offering RTM, enrollment varied by age, was inversely associated with Black race (vs. white), low income, living far from specialty care, and being in the highest quartiles of telehealth use prior to enrollment. Enrollment was positively associated with having osteomyelitis, Charcot foot, a partial foot amputation, BMI≥30 kg/m2, and high outpatient utilization. CONCLUSIONS: RTM growth was concentrated in a small number of higher-resourced facilities, with evidence of lower enrollment among those who were Black and lived farther from specialty care. Future studies are needed to identify and address barriers to uptake of new interventions like RTM to prevent exacerbating existing ulceration and amputation disparities.

  PublisherOA PDFDOI

• Association between adverse childhood experiences and health related quality of life in adult cancer survivors in the United States

  Journal of Cancer Survivorship · 2024-05-03 · 7 citations

  articleOpen access
  PublisherOA PDFDOI

• Association of Achievement of the American Heart Association's Life's Essential 8 Goals With Incident Cardiovascular Diseases in the SHFS

  Journal of the American Heart Association · 2024-03-08 · 18 citations

  articleOpen access

  BACKGROUND: Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in American Indian people. In 2022, the American Heart Association developed the Life's Essential 8 goals to promote cardiovascular health (CVH) for Americans, composed of diet, physical activity, nicotine exposure, sleep, body mass index, blood lipids, blood pressure, and blood glucose. We examined whether achievement of Life's Essential 8 goals was associated with incident CVD among SHFS (Strong Heart Family Study) participants. METHODS AND RESULTS: A total of 2139 SHFS participants without CVD at baseline were included in analyses. We created a composite CVH score based on achievement of Life's Essential 8 goals, excluding sleep. Scores of 0 to 49 represented low CVH, 50 to 69 represented moderate CVH, and 70 to 100 represented high CVH. Incident CVD was defined as incident myocardial infarction, coronary heart disease, congestive heart failure, or stroke. Cox proportional hazard models were used to examine the relationship of CVH and incident CVD. The incidence rate of CVD at the 20-year follow-up was 7.43 per 1000 person-years. Compared with participants with low CVH, participants with moderate and high CVH had a lower risk of incident CVD; the hazard ratios and 95% CIs for incident CVD for moderate and high CVH were 0.52 (95% CI, 0.40-0.68) and 0.25 (95% CI, 0.14-0.44), respectively, after adjustment for age, sex, education, and study site. CONCLUSIONS: Better CVH was associated with lower CVD risk which highlights the need for comprehensive public health interventions targeting CVH promotion to reduce CVD risk in American Indian communities.

  PublisherDOI

Recent grants

• Evaluation of clinical trajectories and identification of modifiable risk factors to improve secondary prevention of amputation in Veterans with diabetes following an initial toe amputation.

  NIH · 2018–2020

Frequent coauthors

• Edward J. Boyko

  VA Puget Sound Health Care System

  131 shared

• Emily White

  Fred Hutch Cancer Center

  87 shared

• Keren Lehavot

  University of Washington

  52 shared

• Thomas L. Vaughan

  47 shared

• Alan R. Kristal

  Fred Hutch Cancer Center

  43 shared

• Emily C. Williams

  VA Puget Sound Health Care System

  42 shared

• Joseph M. Czerniecki

  University of Washington

  42 shared

• Charles Maynard

  University of Washington

  40 shared

Education

• Ph.D., Epidemiology

  University of Washington

  2000

• M.S., Epidemiology

  University of Washington

  1996

• B.A., Biology

  University of California, Los Angeles

  1993