Migraine Prevalence, Environmental Risk, and Comorbidities in Men and Women Veterans.

Importance: Migraine is a prevalent and debilitating condition that substantially impacts quality of life. Investigating migraine prevalence, associated comorbidities, and potential military service exposures in veterans, focusing on gender differences, is crucial for targeted interventions and management strategies. Objective: To determine the prevalence of migraine, associated health comorbidities, and potential military service and environmental exposures among men and women US veterans using a large-scale epidemiological sample from the Million Veteran Program (MVP). Design, Setting, and Participants: This cross-sectional study analyzed self-report survey data from the MVP, a large epidemiological sample of US veterans that was started in 2011 and has ongoing enrollment. Eligible participants were selected from the MVP database in 2023. The study included 491 604 veterans to examine migraine prevalence, health comorbidities, demographic characteristics, military service history, and environmental exposures. Data were analyzed from December 2022 to July 2023. Exposures: Military service and environmental factors, such as chemical or biological warfare exposure, were considered. Main Outcomes and Measures: The primary outcome was migraine prevalence among men and women veterans, assessed through self-reported diagnoses. Secondary outcomes included the association between migraine and health comorbidities, demographic characteristics, military service history, and environmental exposures. Results: Of the 491 604 veterans included in this study, 450 625 (91.8%) were men and 40 979 (8.2%) were women. The lifetime prevalence of migraine was significantly higher in women (12 324 of 40 979 [30.1%]) than in men (36 816 of 450 625 [8.2%]). Migraine prevalence varied by race and ethnicity, with the highest prevalence in Hispanic or Latinx women (1213 of 3495 [34.7%]). Veterans with migraine reported worse general health, higher levels of pain, increased pain interference with work, a higher likelihood of psychiatric and neurological health conditions, and greater lifetime opioid use. Specific aspects of military service, including service post-September 2001 and deployment in Operation Enduring Freedom and Operation Iraqi Freedom, and environmental factors, including Agent Orange, chemical and biological welfare, and antinerve agent pills history, were significantly associated with migraine prevalence. Conclusions and Relevance: In this cross-sectional study of migraine, the results highlighted gender differences in migraine prevalence and associated health comorbidities among US veterans. The findings emphasized the need for interdisciplinary approaches to migraine management, increased awareness and education efforts, and population-based screening strategies, particularly for women and Hispanic veterans who are at greater risk. Our findings encourage further research into tailored interventions for specific subpopulations and the impact of military service and environmental exposures on migraine and related health conditions.

The Impact of COVID-19 on Health Behavior Engagement and Psychological and Physical Health Among Active Duty Military Enrolled in a Weight Management Intervention: An Exploratory Study.

INTRODUCTION: The COVID-19 pandemic profoundly affected the health and well-being of people globally. Some studies suggest individuals with overweight or obesity may have been more adversely impacted by pandemic restrictions. Additionally, military personnel may have been more vulnerable to stress during the pandemic because of job demands (e.g., work in close quarters). Our research group was conducting a randomized clinical trial of a weight management intervention in active duty military personnel with overweight or obesity when the COVID-19 pandemic struck. Thus, we collected additional pandemic-related data from participants enrolled during the COVID-19 pandemic and conducted exploratory analyses to understand how the pandemic affected their stress levels and perceived abilities to engage in health behaviors like exercise and healthy eating. The aims of this exploratory study were to: (1) assess associations between pandemic-related stress and health behaviors with body fat percentage (BF%) and psychological and physical health, and (2) explore how pandemic-related stress and health behaviors affected BF% during and after the intervention. MATERIALS AND METHODS: A total of 29 active duty Navy personnel (55% female, 69% White) were enrolled after the onset of pandemic restrictions and completed measures assessing pandemic-related stress and health behaviors as well as measures of general psychological and physical health before the intervention. BF% was collected at 5 timepoints, including baseline, during, and following the intervention. Bivariate correlations assessed associations at baseline. Linearmixed-effects longitudinal models explored how pandemic-related stress and health behaviors affected BF%. Post-hoc analyses evaluated the effects of pandemic factors on BF% at each timepoint. RESULTS: Most participants perceived of the pandemic as increasing stress and detracting from their abilities to engage in health behaviors (i.e., exercise and healthy eating). Higher pandemic stress was significantly associated with reporting exercise and healthy eating as more difficult, worse overall health, and more anxiety and general stress. Reporting exercise as harder during the pandemic also was associated with more psychological distress at baseline. A linearmixed- effects model controlling for age, sex, and number of intervention sessions attended revealed endorsing "exercise as harder" was associated with higher BF%. Post-hoc regression analyses revealed rating "exercise as harder" significantly predicted higher BF% 3 months post-intervention (B = 0.65, P = .01), whereas pandemic stress was not significantly associated with higher BF% at 3 month (B =0.14, P = .08) or 6 month (B = 0.21, P = .09) follow-up. CONCLUSIONS: As expected, most participants perceived of the pandemic as heightening stress and interfering with engagement in health behaviors. It is possible that pandemic-related stress may have exacerbated weight gain-promoting behaviors and/or interfered with achievement of desired weight management outcomes. Outside the context of the pandemic, it may be beneficial for healthcare providers to screen individuals for stress and perceptions of ease of engagement in health behaviors before enrollment in a weight management intervention. Further, tailoring interventions to mitigate stress and promote perceptions of ease in engaging in health behaviors may promote better weight management outcomes.

Validation of a simple body map to measure widespread pain in urologic chronic pelvic pain syndrome: A MAPP Research Network study.

PURPOSE: In patients with urologic chronic pelvic pain syndrome (UCPPS), the presence of widespread pain appears to identify a distinct phenotype, with a different symptom trajectory and potentially different response to treatment than patients with pelvic pain only. MATERIALS AND METHODS: A 76-site body map was administered four times, at weekly intervals, to 568 male and female UCPPS participants in the MAPP Network protocol. The 76 sites were classified into 13 regions (1 pelvic region and 12 nonpelvic regions). The degree of widespread pain was scored from 0 to 12 based on the number of reported nonpelvic pain regions. This continuous body map score was regressed over other measures of widespread pain, with UCPPS symptom severity, and with psychosocial variables to measure level of association. These models were repeated using an updated body map score (0-12) that incorporated a threshold of pain ≥ 4 at each site. RESULTS: Body map scores showed limited variability over the 4 weekly assessments, indicating that a single baseline assessment was sufficient. The widespread pain score correlated highly with other measures of widespread pain and correlated with worsened UCPPS symptom severity and psychosocial functioning. Incorporating a pain severity threshold ≥4 resulted in only marginal increases in these correlations. CONCLUSIONS: These results support the use of this 13-region body map in the baseline clinical assessment of UCPPS patients. It provides reliable data about the presence of widespread pain and does not require measurement of pain severity, making it relatively simple to use for clinical purposes.

Celiac disease symptom profiles and their relationship to gluten-free diet adherence, mental health, and quality of life.

BACKGROUND: A subgroup of adults with celiac disease experience persistent gastrointestinal and extraintestinal symptoms, which vary between individuals and the cause(s) for which are often unclear. METHODS: The present observational study sought to elucidate patterns of persistent symptoms and the relationship between those patterns and gluten-free diet adherence, psychiatric symptoms, and various aspects of quality of life (QOL) in an online sample of adults with celiac disease. U.S. adults with self-reported, biopsy-confirmed celiac disease (N = 523; Mage = 40.3 years; 88% women; 93.5% White) voluntarily completed questionnaires as part of the iCureCeliac® research network: (a) Celiac Symptoms Index (CSI) for physical symptoms and subjective health; (b) Celiac Dietary Adherence Test for gluten-free diet adherence; (c) PROMIS-29, SF-36, and Celiac Disease Quality of Life Survey for psychiatric symptoms and QOL. Symptom profiles were derived using latent profile analysis and profile differences were examined using auxiliary analyses. RESULTS: Latent profile analysis of CSI items determined a four-profile solution fit best. Profiles were characterized by: (1) little to no symptoms and excellent subjective health (37% of sample); (2) infrequent symptoms and good subjective health (33%); (3) occasional symptoms and fair to poor subjective health (24%); (4) frequent to constant symptoms and fair to poor subjective health (6%). Profiles 2 and 3 reported moderate overall symptomology though Profile 2 reported relatively greater extraintestinal symptoms and Profile 3 reported relatively greater gastrointestinal symptoms, physical pain, and worse subjective health. Profiles differed on anxiety and depression symptoms, limitations due to physical and emotional health, social functioning, and sleep, but not clinical characteristics, gluten-free diet adherence, or QOL. Despite Profile 3's moderate symptom burden and low subjective health as reported on the CSI, Profile 3 reported the lowest psychiatric symptoms and highest quality of life on standardized measures. CONCLUSIONS: Adults with celiac disease reported variable patterns of persistent symptoms, symptom severity, and subjective health. Lack of profile differences in gluten-free diet adherence suggests that adjunctive dietary or medical assessment and intervention may be warranted. Lower persistent symptom burden did not necessarily translate to better mental health and QOL, suggesting that behavioral intervention may be helpful even for those with lower celiac symptom burden.

Associations Among Stress, Internalized Weight Stigma, Emotional Eating, and Body Composition in Active-Duty Service Members Enrolling in a Randomized Controlled Trial of a Weight Management Program.

BACKGROUND: Obesity is a critical public health concern with particular relevance to US military personnel. Stress and internalized weight stigma ("stigma") may contribute to and maintain obesogenic processes and behaviors, including emotional eating. In this secondary cross-sectional analysis, we examined (1) associations among stress and stigma with emotional eating and body fat percentage (BF%), (2) whether stress explains the association between stigma and emotional eating, and (3) whether emotional eating explains associations between stress and stigma with BF%. METHOD: Active-duty military service members (N = 178) completed BF% assessment and questionnaires assessing stress, stigma, and emotional eating. RESULTS: Structural equation modeling path analyses showed that stress and stigma were both significantly associated with emotional eating (b = 0.35, p < 0.001 and b = 0.23, p < 0.001, respectively) and with BF% (b = 0.38, p < 0.001 and b = 0.29, p < 0.001, respectively) such that individuals who reported higher stress and stigma tended to report more emotional eating and had higher BF%. Stress partially explained the association between internalized weight stigma and emotional eating, and emotional eating partially explained the relationship between stress and BF% but did not significantly mediate the association between stigma and BF%. CONCLUSION: Greater stress and internalized weight stigma were associated with more emotional eating and higher BF%; however, emotional eating only partially explained the association between stress and BF%. Results highlight the importance of interventions targeting stress management skills, but additional research is needed to identify mechanisms that explain the association between stigma and BF%.

Functional decline during the COVID-19 pandemic among U.S. military veterans: Results from the National Health and Resilience in Veterans Study.

OBJECTIVES: The coronavirus disease-2019 pandemic has contributed to widespread social and economic stressors, along with substantial health problems, including loss of life. To date, however, relatively few studies have examined the prevalence and correlates of declines in mental and physical functioning in U.S. military veterans, an older and potentially vulnerable segment of the U.S. adult population. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative, longitudinal study of 3078 veterans. Veterans were surveyed prior to the pandemic (pre-pandemic) and 1 year later during the height of the pandemic (peri-pandemic). Multivariable analyses were conducted to identify risk and protective variables associated with pre-to-peri pandemic declines in self-reported physical and mental functioning. RESULTS: The prevalence of veterans who experienced functional decline (≥0.5 standard deviation reductions) pre-to-peri-pandemic was 18.1% (N = 541) for physical functioning and 18.3% (N = 547) for mental functioning. Older age, greater adverse childhood experiences (ACEs), and pandemic-related posttraumatic stress symptoms were the strongest correlates of physical functional decline, while greater ACEs, loneliness, pandemic-related posttraumatic and social restriction stress symptoms, and lower protective psychosocial characteristics were the strongest correlates of mental functional decline. CONCLUSIONS: Although the majority of U.S. Veterans showed functional maintenance or improvement 1 year into the pandemic, nearly one-in-five experienced a decline in physical or mental functioning. Results could help inform identification of veterans who may be at risk for functional decline during large-magnitude stressors, such as national or global pandemics.

Daily Functioning of Veterans With Type 2 Diabetes: Protocol for an Ambulatory Assessment Study.

BACKGROUND: Diabetes impacts nearly 25% of veterans. Many veterans do not engage in recommended physical activity and other diabetes self-management behaviors. Type 2 diabetes is generally asymptomatic; as such, the long-term consequences of inadequate self-management and benefits of consistent self-management are not salient in the short term. Furthermore, self-management behaviors typically take place outside of medical visits; however, self-management-related factors are only assessed during medical visits, likely missing large amounts of variability. Thus, ambulatory assessment methods such as ecological momentary assessment (EMA), accelerometry, and continuous glucose monitoring are needed to understand the dynamics of daily self-management and identify potential intervention targets. OBJECTIVE: The overarching goal of this study is to understand daily, time-varying factors (comorbid affective symptoms and social context) that influence physical activity, diabetes self-management, glycemic management, daily functioning, and quality of life in participants' natural environments. METHODS: We are recruiting veterans with type 2 diabetes (target N=100). Participants are required to complete a battery of baseline assessments related to mental health, psychosocial factors, and self-management behaviors. Participants then receive 5 momentary EMA surveys and 1 daily EMA survey per day, in which veterans report comorbid affective symptoms (mood, stress, and pain), social support, social interactions, physical activity, and other self-management behaviors. Momentary surveys are delivered randomly during daily preprogrammed intervals over a 14-day sampling period. Accelerometry and continuous glucose monitoring are also used to assess physical activity and blood glucose, respectively. The first 6 participants also completed interviews assessing their experience in the study and barriers to participation. These test participants informed modifications to the protocol for the remaining participants. RESULTS: The project received funding in April of 2023. Enrollment began in March of 2023 and is planned to be completed in April 2025. Among the 6 test participants, the overall EMA response rate was 87% (range 74%-95%). The response rate for the EMA survey including daily items (67%, range 21%-93%) was lower than the earlier shorter EMA surveys (89%, range 81%-96%). The mean rate of valid accelerometer wear of at least 20 hours per day was 93% (SD 11%), and continuous glucose monitoring data were available for 91% (SD 17%) of days on average. Participants reported few barriers to completing EMA surveys but noted the random timing of questions made it difficult to plan around, and the end-of-day survey was long. Two participants reported survey items reminded or motivated them to engage in diabetes self-management behaviors. CONCLUSIONS: Assessment tools developed from this study can inform clinical decision-making by considering barriers to self-management that occur in daily life. Clinical applications include tailored, adaptive technology-supported interventions to improve self-management that provide the right type and amount of support at the right time by adapting to an individual's changing internal and contextual state. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/53874.

Symptoms of major depressive disorder and post-traumatic stress disorder in veterans with mild traumatic brain injury: A network analysis.

Mild Traumatic Brain Injury (mTBI, or concussion) is a debilitating condition that often leads to persistent cognitive and mental health problems post-injury. Post-traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) are two most commonly occurring mental health problems following mTBI and are suggested to be strong contributors to the persistent post-concussion symptoms. Thus, it is important to understand the symptomatology of PTSD and MDD post-mTBI, to better inform targets for behavioral health interventions. Therefore, the current study examined the symptom structure of post-mTBI co-morbid PTSD and MDD through network approaches; we compared the network structure of participants with a positive mTBI screen (N = 753) to the network structure of participants with a negative mTBI screen (N = 2044); lastly, we examined a network of PTSD and MDD symptoms with clinical covariates in a positive mTBI sample. We found that feeling distant/cutoff (P10) and difficulty concentrating (P15) were the most central symptoms in the positive mTBI network and sleep problems were the most prominent bridge nodes across the disorders. No significant difference between the positive and negative mTBI network were found through network comparison tests. Moreover, anxiety and insomnia were strongly associated with sleep symptoms and irritability symptoms, and emotional support and resilience were potential buffers against most of the PTSD and MDD symptoms. The results of this study might be particularly useful for identifying targets (i.e., feeling distant, concentration and sleep problems) for screening, monitoring and treatment after concussion to better inform post-mTBI mental health care and to improve treatment outcomes.

Design of the CHARGE study: A randomized control trial evaluating a novel treatment for Veterans with binge eating disorder and overweight and obesity.

A large number of Veterans experience binge eating and overweight or obesity, which are associated with significant health and psychological consequences. The gold-standard program for the treatment of binge eating, Cognitive Behavioral Therapy (CBT), results in decreases in binge eating frequency but does not result in significant weight loss. We developed the Regulation of Cues (ROC) program to reduce overeating and binge eating through improvement in sensitivity to appetitive cues and decreased responsivity to external cues, an approach that has never been tested among Veterans. In this study, we combined ROC with energy restriction recommendations from behavioral weight loss (ROC+). This study is a 2-arm randomized controlled trial designed to evaluate the feasibility and acceptability of ROC+, and to compare the efficacy of ROC+ and CBT on reduction of binge eating, weight, and energy intake over 5-months of treatment and 6-month follow-up. Study recruitment completed in March 2022. One hundred and twenty-nine Veterans were randomized (mean age = 47.10 (sd = 11.3) years; 41% female, mean BMI = 34.8 (sd = 4.7); 33% Hispanic) and assessments were conducted at baseline, during treatment and at post-treatment. The final 6-month follow-ups will be completed in April 2023. Targeting novel mechanisms including sensitivity to internal cures and responsivity to external cues is critically important to improve binge eating and weight-loss programs among Veterans. Clinicaltrials.govNCT03678766.

Mediators of the association between childhood trauma and pain sensitivity in adulthood: a Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network analysis.

ABSTRACT: Urologic chronic pelvic pain syndrome (UCPPS) is a complex, debilitating condition in which patients often report nonpelvic pain in addition to localized pelvic pain. Understanding differential predictors of pelvic pain only vs widespread pain may provide novel pathways for intervention. This study leveraged baseline data from the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network's Symptom Pattern Study to investigate the impact of childhood sexual and nonsexual violent trauma on pelvic and nonpelvic pain sensitivity among adult patients with UCPPS, as well as potential mediators of this association. Study participants who met inclusion criteria for UCPPS completed questionnaires assessing childhood and recent trauma, affective distress, cognitive dysfunction, and generalized sensory sensitivity. Experimental pain sensitivity was also evaluated using standardized pressure pain applied to the pubic region and the arm. Bivariate analyses showed that childhood violent trauma was associated with more nonviolent childhood trauma, more recent trauma, poorer adult functioning, and greater pain sensitivity at the pubic region, but not pain sensitivity at the arm. Path analysis suggested that childhood violent trauma was indirectly associated with pain sensitivity at both sites and that this indirect association was primarily mediated by generalized sensory sensitivity. More experiences of recent trauma also contributed to these indirect effects. The findings suggest that, among participants with UCPPS, childhood violent trauma may be associated with heightened pain sensitivity to the extent that trauma history is associated with a subsequent increase in generalized sensory sensitivity.

Psychometric validation of the celiac disease-specific quality of life survey (CD-QOL) in adults with celiac disease in the United States.

PURPOSE: Celiac disease and its treatment negatively impact quality of life, indicating potential need for measurement of disease-specific quality of life domains to inform interdisciplinary intervention. The Celiac Disease Quality of Life Survey (CD-QOL) has been used in clinical research; however, its factor structure has not been confirmed and psychometric properties have not been evaluated in English-speaking adults in the U.S. AIMS: (1) Confirm the factor structure of the 20-item English CD-QOL; (2) assess psychometric properties including internal consistency reliability, convergent validity, known groups validity, and incremental validity. METHODS: 453 adults with self-reported Celiac disease (Mage = 40.57; 88% female; 92% White) completed the CD-QOL and validated measures of generic health-related quality of life (SF-36), gluten-free diet adherence (CDAT), anxiety and depression symptoms (PROMIS), and physical symptoms (CSI) as part of the iCureCeliac® patient-powered research network. RESULTS: Confirmatory factor analysis found superior fit for a bifactor structure with one general factor and four group factors. Ancillary bifactor analyses suggest the CD-QOL can be considered primarily unidimensional. Total and three subscale scores demonstrated acceptable internal consistency reliability. Convergent and known groups validity were supported. The CD-QOL demonstrated some incremental validity over the SF-36. CONCLUSION: The English CD-QOL can be used as a measure of disease-specific quality of life among adults with Celiac disease in the U.S. Compared to generic instruments, the CD-QOL appears to better capture specific cognitive and affective aspects of living with Celiac disease. Use of a total score is recommended. Its utility as a screening and outcome measurement tool in clinical settings should be examined.

Associations among meaning in life, coping, and distress in trauma-exposed U.S. military veterans.

Experiencing meaning in life may be particularly relevant following traumatic experiences as individuals who report meaning post trauma report less psychological distress. Engaging in avoidant coping, however, may be a sign of underlying psychological distress in the aftermath of traumatic experiences. We sought to examine associations among meaning in life, avoidant coping, and psychological distress in a sample of trauma-exposed veterans. Secondary cross-sectional analyses were conducted on data from veterans exposed to a traumatic event(s) who experienced clinically meaningful guilt (N = 145). Questionnaires on meaning in life, avoidant coping, and psychological distress were administered, and structural equation modeling was used to test direct effects. Path analysis revealed that greater meaning was associated with lower depression, anxiety, and posttraumatic stress symptomatology, while higher avoidant coping was associated with greater depression, anxiety, posttraumatic stress, and somatization symptomatology. Participants who report more meaning in life and report lower avoidant coping post trauma may experience less psychological distress. If replicated longitudinally, results could suggest cultivating meaning in life and reducing avoidant coping may decrease psychological distress. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Clinically Important Differences for Pain and Urinary Symptoms in Urological Chronic Pelvic Pain Syndrome: A MAPP Network Study.

PURPOSE: Symptom heterogeneity in interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome, collectively termed urological chronic pelvic pain syndrome, has resulted in difficulty in defining appropriate clinical trial endpoints. We determine clinically important differences for 2 primary symptom measures, pelvic pain severity and urinary symptom severity, and evaluate subgroup differences. MATERIALS AND METHODS: The Multidisciplinary Approach to the Study of Chronic Pelvic Pain Symptom Patterns Study enrolled individuals with urological chronic pelvic pain syndrome. We defined clinically important differences by associating changes in pelvic pain severity and urinary symptom severity over 3 to 6 months with marked improvement on a global response assessment using regression and receiver operating characteristic curves. We evaluated clinically important differences for absolute and percent change and examined differences in clinically important differences by sex-diagnosis, presence of Hunner lesions, pain type, pain widespreadness, and baseline symptom severity. RESULTS: An absolute change of -4 was clinically important in pelvic pain severity among all patients, but clinically important difference estimates differed by pain type, presence of Hunner lesions, and baseline severity. Pelvic pain severity clinically important difference estimates for percent change were more consistent across subgroups and ranged from 30% to 57%. The absolute change urinary symptom severity clinically important difference was -3 for female participants and -2 for male participants with chronic prostatitis/chronic pelvic pain syndrome only. Patients with greater baseline severity required larger decreases in symptoms to feel improved. Estimated clinically important differences had lower accuracy among participants with low baseline symptoms. CONCLUSIONS: A reduction of 30%-50% in pelvic pain severity is a clinically meaningful endpoint for future therapeutic trials in urological chronic pelvic pain syndrome. Urinary symptom severity clinically important differences are more appropriately defined separately for male and female participants.

Prevalence, characteristics, and health burden of rheumatoid arthritis in the U.S. veteran population.

OBJECTIVE: To examine the prevalence, characteristics, and physical and mental health burden of rheumatoid arthritis (RA) in a nationally representative sample of U.S. military veterans. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (NHRVS), which surveyed a contemporary, nationally representative sample of 4,069 U.S. veterans. Veterans with RA (n = 227) were compared to veterans with any other medical condition(s) (n = 3,444) on measures of sociodemographic, military, trauma, medical and psychiatric characteristics. Multivariable analyses were then conducted to examine independent associations between RA and health conditions. RESULTS: A total of 5.3% (95% confidence interval = 4.5-6.2%) of primarily male U.S. veterans reported having been diagnosed with RA. Relative to controls, veterans with RA were older, and more likely to be racial/ethnic minorities, unpartnered, lower income, and combat veterans. They also reported greater cumulative trauma burden, more medical conditions (i.e., osteoarthritis, chronic pain, respiratory and cardiovascular conditions), and greater severity of somatic symptoms, and were more likely to screen positive for current insomnia and subthreshold posttraumatic stress disorder (PTSD), and lifetime alcohol use disorder (AUD). In adjusted analyses, RA remained associated with number of medical conditions, more severe somatic symptoms, insomnia, subthreshold PTSD, and AUD. CONCLUSIONS: One of 20 U.S. veterans has RA, which is more prevalent among certain sociodemographic subsets, and is associated with elevated physical and mental health burden. Results provide insight into risk correlates of RA and underscore the importance of assessing, monitoring, and treating medical and psychiatric conditions/symptoms that co-occur with RA in this population.

Patterns of adverse childhood experiences and cardiovascular risk factors in U.S. adults.

Adverse Childhood Experiences (ACEs) are associated with poor health yet, we know little about how distinct patterns of ACE types are associated with cardiovascular (cardiovascular (CVD)) risk factors. The current study 1) examined associations of latent ACE classes with modifiable CVD risk factors including high cholesterol, smoking, diabetes, hypertension, high triglycerides, physical inactivity, overweight/obesity, and lifetime depression; and 2) examined the impact of socioeconomic status-related (SES) factors on these relationships. Using a cross-sectional analysis of the National Epidemiologic Survey of Alcohol and Related Conditions-III (n = 36,309) data, four latent classes of ACEs were previously identified: 1) low adversity, 2) primarily household dysfunction, 3) primarily maltreatment, and 4) multiple adversity types. We examined the association of these classes with CVD risk factors in adulthood and subsequently, the same model accounting for SES-related factors. Tobacco smoking, overweight/obesity, and lifetime depression were each associated with higher odds of being in classes 2, 3, and 4 than class 1, respectively. These relationships held after adjusting for SES-related factors. Class 4 was associated with the most CVD risk factors, including high triglycerides and high cholesterol after controlling for SES-related factors. The consistent associations between tobacco smoking, overweight/obesity, and lifetime depression with each adverse ACE profile, even after controlling for SES, suggest behavioural CVD prevention programs should target these CVD risk factors simultaneously.

Characteristics of Active Duty Service Members Referred to the Navy's Weight-Management Program.

INTRODUCTION: Rates of overweight and obesity have increased in the military, particularly in the U.S. Navy. While the Navy has implemented weight-management programs like ShipShape, findings on the effectiveness of these programs are mixed. Further knowledge on the characteristics of service members (SMs) who participate in these programs may help inform course curricula and improve outcomes. This study aimed to (1) examine characteristics of SMs referred to the Navy's ShipShape program at a large military treatment facility, (2) compare these characteristics among SMs who did and did not enroll in a randomized clinical trial of ShipShape (ShipShape study participants), and (3) compare demographic and health characteristics of ShipShape study participants to that of a random and similarly sized sample of Navy SMs who responded to the 2015 DoD Health-Related Behaviors Survey (HRBS). MATERIALS AND METHODS: Data from active duty Navy SMs referred to the ShipShape program at a large military treatment facility were evaluated (n = 225). A subset of these SMs enrolled in the ShipShape study (n = 187). Among enrolled SMs, data from 147 who completed all measures were compared to that of HRBS respondents. Univariate ANOVA and chi-square analyses were used to examine (1) demographic and motivational differences between SMs who did and did not enroll in the ShipShape study and (2) differences in demographics and medical and mental health conditions between ShipShape study participants and Navy HRBS respondents. RESULTS: The majority of SMs referred to ShipShape were female with an average age of 28.3 years. Compared to SMs who did not enroll in the ShipShape study (n = 38), ShipShape study participants were more likely to be female, less likely to be Hispanic, and had higher motivation and emotional eating scores. Compared to Navy HRBS respondents (n = 164), ShipShape study participants (n = 147) were younger, more likely to be female, non-Hispanic, enlisted, and obese. Further, ShipShape study participants reported significantly fewer medical health conditions but higher rates of probable depression, anxiety, and PTSD and were more likely to report receiving current mental health treatment than HRBS respondents. CONCLUSION: Overweight or obese SMs seeking weight loss in the ShipShape study were relatively young, female, non-Hispanic, motivated, but with greater emotional eating. ShipShape study participants endorsed few medical health conditions but had higher rates of probable mental health conditions compared to the HRBS sample. These findings suggest that SMs referred to Navy weight-management programs are likely experiencing comorbid mental health conditions which may interfere with the effectiveness of their weight loss efforts. The descriptive nature of this study and the focus on Navy SMs in only one ShipShape program may decrease the generalizability of our findings to participants at other locations. Nonetheless, these findings demonstrate the potential need for Navy weight-management programs that incorporate mental health treatment and address the specific needs of female and diverse SMs. A more comprehensive curriculum could improve the results of weight-management efforts, increase SM quality of life and fitness and thereby operational readiness.

Confirmatory Factor Analysis of the Comprehensive Assessment of Acceptance and Commitment Therapy (CompACT) in Active-Duty Military Personnel.

Acceptance and Commitment Therapy (ACT) is a third-wave cognitive-behavioral treatment that targets psychological flexibility (PF), or the ability to persist in behavior consistent with values regardless of unwanted private experiences. The growing use of ACT necessitates an accurate assessment of PF. The Comprehensive Assessment of Acceptance and Commitment Therapy (CompACT) is a three-factor measure of PF (Openness to Experience, Valued Action, and Behavioral Awareness) whose psychometric properties have been examined in limited populations. The current study examined the factor structure and psychometric properties of the CompACT in U.S. military personnel who enrolled in a weight management randomized controlled trial. Military personnel who either failed or were at risk of failing the Navy's physical fitness assessment or had overweight/obese body mass index (BMI; N = 178, Mage = 29.15 years; MBMI = 33.13 kg/m2; 61.8% female) completed the CompACT and other questionnaires. Confirmatory factor analysis was used to evaluate the three-factor structure of the original 23-item CompACT (CompACT-23) as well as an 18-item version identified in a Portuguese sample (CompACT-18). Internal consistency and convergent validity with measures of weight-related experiential avoidance, perceived stress, anxiety, depression, PTSD symptoms, and life satisfaction were examined. The three-factor structure of the CompACT-23 showed poor fit to the data while the fit of the CompACT-18 was acceptable, as indicated by three descriptive indices (χ2/df = 1.73, RMSEA = 0.069, SRMR = 0.074). All descriptive fit indices in addition to two comparative fit indices (AIC and BIC) indicated improved model fit over the CompACT-23. The CompACT-18 and its subscales exhibited adequate internal consistency (α = 0.768 to 0.861) and convergent validity in expected directions with measures of weight-related experiential avoidance, perceived stress, anxiety, depression, PTSD symptoms, and satisfaction with life. Results support using the refined, English language CompACT-18 as a three-factor measure of PF in populations such as U.S. military personnel who may benefit from weight management intervention. Future research should explore the content validity of the full measure and the removed items. Lost content could mean the CompACT-23 and the CompACT-18 differentially assess PF. Additional studies should examine psychometric properties in large and more diverse samples to further evaluate the appropriateness of the measure across populations. Longitudinal studies are needed to examine test-retest reliability and sensitivity to change.

Lessons Learned From Transition of an In-Person to a Virtual Randomized Controlled Trial for Weight and Fitness Concerns in Active-Duty Service Members: Survey Study.

BACKGROUND: This paper describes and discusses the transition of and modifications to a weight management randomized controlled trial among active-duty military personnel from an in-person to a virtual format as a result of the COVID-19 pandemic. The original pragmatic cohort-randomized controlled trial was designed to compare the effectiveness of an 8-week group weight management program, ShipShape, to a version of ShipShape enhanced with acceptance and commitment therapy. OBJECTIVE: The objective of our study was to assess potential differences between in-person and virtual participation in participants' demographics, motivation, confidence, credibility, expectations, and satisfaction with the interventions; we also examined the pragmatics of the technology and participants' experiences in virtual-format intervention groups. METHODS: A total of 178 active-duty personnel who had failed or were at risk of failing their physical fitness assessment or were overweight or obese were enrolled in the study. In-person (n=149) and virtual (n=29) participants reported demographics, motivation, confidence, credibility, expectations, and satisfaction. Interventionists recorded attendance and participation in the group sessions. Independent-sample 2-tailed t tests and chi-square tests were used to compare the characteristics of the in-person and virtual participants. Pragmatics of the technology and participants' experiences in the virtual format were assessed through surveys and open-ended questions. RESULTS: Participants were 29.7 (SD 6.9) years old on average, 61.8% (110/178) female, and 59.6% (106/178) White and had an average BMI of 33.1 (SD 3.9) kg/m2. Participants were highly motivated to participate and confident in their ability to complete a weight management program. A total of 82.6% (147/178) of all participants attended 5 of the 8 sessions, and participation was rated as "excellent" by interventionists in both formats. The interventions were found to be credible and to have adequate expectations for effectiveness and high satisfaction in both formats. There were no differences between in-person and virtual participants in any of these metrics, other than interventionist-rated participation, for which virtual participants had significantly higher ratings (P<.001). Technical satisfaction with the virtual sessions was rated as "good" to "very good," and participants were satisfied with the content of the virtual sessions. A word cloud of responses identified "mindfulness," "helpful," "different," "food," "binder," and "class" as concepts the virtual participants found most useful about the program. CONCLUSIONS: Modifications made in response to the COVID-19 pandemic were successful, given the recruitment of active-duty personnel with similar demographic characteristics, attendance levels, and indicators of credibility, expectancy, and satisfaction in the virtual format and the in-person format. This successful transition provides support for the use of virtual or digital weight management interventions to increase accessibility and reach among highly mobile active-duty personnel. TRIAL REGISTRATION: ClinicalTrials.gov NCT03029507; https://clinicaltrials.gov/ct2/show/NCT03029507.

Baseline Characteristics and Their Associations with Body Composition of Active-Duty Service Members Enrolling in a Randomized Controlled Trial of a Weight Management Program.

INTRODUCTION: Increasing rates of overweight and obesity among military service members (SMs) necessitate the implementation of weight management interventions. Evidence for the effectiveness of military weight management interventions is mixed. Effectiveness may be impacted by individual sociodemographic, psychiatric, psychological, and behavioral factors. Baseline data from SMs who were overweight/obese or at risk of failing body composition or physical fitness tests and enrolling in a weight management randomized controlled trial were used to examine (1) individual characteristics of this sample as a whole and by gender and (2) relationships between those characteristics and body composition metrics that are targeted by military weight management interventions. Understanding these relationships may inform intervention approaches. MATERIALS AND METHODS: Active duty SMs (N = 178) who enrolled in a randomized clinical trial of the Navy's weight management program "ShipShape" at a large military hospital provided data at their baseline visit. Because of gender differences in average body fat percentage (BF%) and underrepresentation of women SMs in research, independent samples t-tests and chi-square analyses were used to examine differences between male and female SMs across study variables. Multiple regression analyses were used to examine relationships of sociodemographic, psychiatric, psychological, and behavioral variables with body composition metrics, including weight, body mass index (BMI), BF%, and waist circumference (WC). RESULTS: Participants (61% female; Mage = 29.66 ± 6.92 years; 59.60% White) had an average BMI in the "obese" range (MBMI = 33.1 ± 3.9 kg/m2). Female participants had significantly higher BF% and significantly lower weight and WC than male participants. Compared to male participants, females reported significantly higher rates of pain and headache diagnoses, lifetime diagnosis of an anxiety disorder, lifetime treatment for a mental health concern, lifetime experiences of sexual trauma/harassment and military sexual trauma, and higher current anxiety and post-traumatic stress disorder symptoms. Across all SMs, body composition metrics were significantly associated with several demographic variables, including gender, age, marital status, Asian race, and Black race. Higher weight-related stigma was significantly associated with higher weight, BMI, BF%, and WC. Additionally, more emotional eating was significantly associated with higher BF%, and higher weight-loss confidence was significantly associated with higher BMI. Sociodemographic, psychiatric, psychological, and behavioral variables predicted the greatest variance in BF% compared to other body composition metrics evaluated. CONCLUSIONS: Participants in this study were more likely to be female, relatively young members of the Navy with overweight/obesity, who endorsed pain-related medical conditions, probable mental health conditions, and traumatic experiences at relatively high rates. Despite high endorsement of anxiety, depression, and post-traumatic stress disorder symptoms in this group, only weight-related stigma consistently emerged as significantly associated with body composition metrics. Regression results varied by body composition metric, with the most variance explained in BF%, suggesting that BF% may relate most strongly to sociodemographic, psychiatric, psychological, and behavioral variables associated with weight management. These results highlight the need for weight management programs that address weight-related stigma and mental health concerns of SMs to maximize the effectiveness of intervention efforts.

An integrated mindfulness meditation and acceptance and commitment therapy intervention for chronic pain: Rationale, design, and methodology of a pilot randomized controlled trial of Acting with Mindfulness for Pain (AMP).

Acceptance and commitment therapy (ACT) is an evidence-based psychosocial intervention for chronic pain; however, in its present form ACT produces modest improvements in function and is no more effective than cognitive behavioral therapy (CBT), the current gold standard. This protocol paper describes the Acting with Mindfulness for Pain (AMP) protocol, which emphasizes and integrates formal mindfulness meditation practice within an ACT-based approach. This paper presents the rationale, design and methodology of an ongoing pilot randomized controlled trial (RCT) comparing AMP to CBT among Veterans with chronic pain (N = 86). Specifically, we argue that formal meditation practice is a necessary treatment component that directly targets key ACT processes which will help facilitate large treatment effects on function (e.g., general activity, social relationships, life enjoyment) among individuals with chronic pain. This study will be the first to consider formal mindfulness meditation practice as a principal treatment ingredient in the context of ACT for chronic pain. The purpose of this trial is to evaluate the feasibility of recruitment and collection of measures, and to examine preliminary treatment effects to determine the appropriateness of a subsequent full-scale RCT. This study will also explore within and between group change on primary and secondary outcomes including pain interference, pain acceptance, trait mindfulness, pain catastrophizing, values-based living, quality of life, practice adherence, and objective measures of physical activity. This study will help delineate the role of formal mindfulness practice within an ACT-based approach for chronic pain and provide preliminary data for a future fully powered RCT.