Racial, Ethnic, and Sex Disparities in Mental Health Among US Service Members and Veterans: Findings From the Millennium Cohort Study.

Although disparities in mental health occur within racially, ethnically, and sex-diverse civilian populations, it is unclear whether these disparities persist within US military populations. Using cross-sectional data from the Millennium Cohort Study (2014-2016; n = 103,184; 70.3% male; 75.7% non-Hispanic White), a series of logistic regression analyses were conducted to examine whether racial, ethnic, and/or sex disparities were found in mental health outcomes (posttraumatic stress disorder (PTSD), depression, anxiety, and problematic anger), hierarchically adjusting for sociodemographic, military, health-related, and social support factors. Compared with non-Hispanic White individuals, those who identified as American Indian/Alaska Native, non-Hispanic Black, Hispanic/Latino, or multiracial showed greater risk of PTSD, depression, anxiety, and problematic anger in unadjusted models. Racial and ethnic disparities in mental health were partially explained by health-related and social support factors. Women showed greater risk of depression and anxiety and lower risk of PTSD than men. Evidence of intersectionality emerged for problematic anger among Hispanic/Latino and Asian or Pacific Islander women. Overall, racial, ethnic, and sex disparities in mental health persisted among service members and veterans. Future research and interventions are recommended to reduce these disparities and improve the health and well-being of diverse service members and veterans.

Risk and Protective Factors for Cancer Mortality among United States Service Members and Veterans (2001-2018).

BACKGROUND: Prior research linking military factors with cancer-specific mortality has shown inconsistent findings, with few studies examining these associations among U.S. service members and veterans who served in Operation Iraqi Freedom/Operation Enduring Freedom conflicts. METHODS: Cancer mortality between 2001 and 2018 was ascertained from the Department of Defense Medical Mortality Registry and National Death Index for 194,689 Millennium Cohort Study participants. Cause-specific Cox proportional hazard models were used to examine links between military characteristics and cancer mortality [overall, early (<45 years), and lung]. RESULTS: Compared with individuals who deployed with no combat experiences, non-deployers had a greater risk of overall [HR = 1.34; 95% confidence interval (CI) = 1.01-1.77] and early cancer mortality (HR = 1.80; 95% CI = 1.06-3.04). Enlisted individuals had a greater risk of lung cancer mortality compared with officers (HR = 2.65; 95% CI = 1.27-5.53). No associations by service component, branch, or military occupation and cancer mortality were observed. Higher education was associated with reduced overall, early and lung cancer mortality risk and smoking and life stressors were associated with elevated overall and lung cancer mortality risk. CONCLUSIONS: These findings are consistent with the healthy deployer effect in which military personnel who were deployed tend to be healthier than those who did not deploy. Further, these findings highlight the importance of considering socioeconomic factors, such as military rank, that may have long-term implications for health. IMPACT: These findings highlight military occupational factors that may predict long-term health outcomes. Additional work is necessary to investigate more nuanced environmental and occupational military exposures and cancer mortality.

The bi-directional relationship between post-traumatic stress disorder and obstructive sleep apnea and/or insomnia in a large U.S. military cohort.

OBJECTIVES: Determine if a bi-directional relationship exists between the development of sleep disorders (obstructive sleep apnea [OSA] and/or insomnia) and existing post-traumatic stress disorder (PTSD), and vice versa; and examine military-related factors associated with these potential relationships. DESIGN: Longitudinal analyses of a prospective representative U.S. military cohort. PARTICIPANTS: Millennium Cohort Study responders in 2011-2013 (Time 1 [T1]) and 2014-2016 (Time 2 [T2]) without insomnia or OSA at T1 (N = 65,915) or without PTSD at T1 (N = 71,256). MEASUREMENTS: Provider-diagnosed OSA, self-reported items for insomnia, provider-diagnosed PTSD, and current PTSD symptoms were assessed at T1 and T2. Adjusted multivariable models identified military-related factors associated with new-onset PTSD in those with OSA and/or insomnia, and vice versa. RESULTS: Self-reported history of provider-diagnosed PTSD without current symptoms at T1 was associated with new-onset OSA only and comorbid OSA/insomnia at T2, while current PTSD symptoms and/or diagnosis was associated with new-onset insomnia only. OSA/insomnia at T1 was consistently associated with newly reported PTSD symptoms or diagnosis except that insomnia only was not associated with newly reported provider-diagnosed PTSD. Military-related risk factors significantly associated with the bi-directional relationship for new-onset PTSD or OSA/insomnia included prior deployment with higher combat exposure and recent separation from the military; being an officer was protective for both outcomes. CONCLUSIONS: In this large military cohort, findings suggest that PTSD and OSA and/or insomnia are bi-directionally predictive for their development, which was sometimes revealed by health care utilization. Relevant military-related risk factors should be considered in efforts to prevent or treat PTSD and/or sleep disorders.

Health Disparities Among Lesbian, Gay, and Bisexual Service Members and Veterans.

INTRODUCTION: This study investigated whether health disparities exist among lesbian, gay, and bisexual individuals serving in the U.S. military by examining the associations of sexual orientation with mental, physical, and behavioral health among a population-based sample of service members and veterans. METHODS: Sexual orientation and health outcomes were self-reported on the 2016 Millennium Cohort Study follow-up questionnaire (N=96,930). Health outcomes were assessed across 3 domains: mental health (post-traumatic stress disorder, depression, anxiety, binge eating, problematic anger), physical health (multiple somatic symptoms, physical functioning, BMI), and behavioral health (smoking, problem and risky drinking, insomnia). Adjusted logistic regression models conducted between 2019 and 2022 estimated the associations between sexual orientation and each health outcome. RESULTS: Lesbian, gay, and bisexual individuals (3.6% of the sample) were more likely to screen positive for post-traumatic stress disorder, depression, anxiety, binge eating, problematic anger, multiple somatic symptoms, and insomnia than heterosexual individuals. Gay/lesbian and bisexual women reported more adverse health outcomes (overweight and obesity, smoking, problem/risky drinking) than heterosexual women. Gay and bisexual men reported some adverse health outcomes (e.g., smoking and problem drinking) but better physical health (e.g., less overweight/obesity) than heterosexual men. CONCLUSIONS: Lesbian, gay, and bisexual service members reported poorer mental, physical, and behavioral health than heterosexual peers, most notably among gay/lesbian women and bisexual individuals. Findings suggest that lesbian, gay, and bisexual service members experience health disparities, despite many having equal eligibility for health care, highlighting the need for improved equity initiatives that promote cultural responsiveness, acceptance, and approaches to support the healthcare needs of lesbian, gay, and bisexual military members.

Association of deployment with maintenance of healthy weight among active duty service members in the Millennium Cohort Study.

Objective: Understanding body size in relation to deployment readiness can inform Department of Defense fitness policies. This study examined longitudinal associations between deployment and changes in body mass index (BMI) among active duty service members. Methods: Service branch-specific changes in BMI post-deployment were examined using logistic regression models among active duty Millennium Cohort Study participants without obesity at baseline (n = 22,995). BMI was categorized using self-reported height and weight as healthy weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30 kg/m2). Number of deployments between baseline and follow-up and initial deployment lengths (in months, using service branch-specific deployment times) were examined. Results: Among the pooled population and specifically Army and Marine Corps service members without obesity, those with longer deployments were significantly less likely to maintain a non-obese BMI than those deploying for shorter lengths. Each additional deployment increased the likelihood of maintaining a non-obese BMI post-deployment for personnel in the Army, Marine Corps, and within the pooled population. Conclusions: Multiple deployments may support healthy weight maintenance; longer deployments may adversely impact weight maintenance. Future research should determine modifiable behaviors related to weight gain post-deployment to inform fitness policies designed to optimize service member readiness and deployability.

A temporal analysis of mental health symptoms relative to separation from the military.

BACKGROUND: The transition from military to civilian life is a dramatic change that is often stressful for veterans. However, little is known regarding how mental health symptoms fluctuate in the period leading up to and following separation from the military. METHODS: The current study examined posttraumatic stress disorder and depression symptoms reported on surveys completed within 1 year of military separation from 23,887 active duty Millennium Cohort Study participants. A series of general linear models and graphs stratified by demographic and military characteristics examined the association between time until/since separation and mental health symptoms. RESULTS: Character of discharge had the most striking relationship between time until/since separation and mental health. Personnel with Honorable discharges did not differ in their level of mental health symptoms across the study period. In contrast, personnel with Other than Honorable/General discharges reported normal levels of mental health symptoms 1 year-prior to separation but reported progressively greater symptoms leading to separation which persisted through the remainder of study period. CONCLUSIONS: This study suggests that additional outreach is needed for personnel with Other than Honorable/General discharges. However, for most other personnel, increased mental health symptomatology around military separation is not a normative phenomenon and any instance should be treated promptly.

Military service experiences and reasons for service separation among lesbian, gay, and bisexual individuals in a large military cohort.

BACKGROUND: The well-being of lesbian, gay, and bisexual (LGB) individuals is a topic of increasing concern within the military where significant institutional barriers, targeted aggression, and differential organizational policies such as "Don't Ask Don't Tell" have historically contributed to experiences of exclusion and discrimination. However, limited research has examined specific military and post-separation experiences among LGB service members and veterans. The goal of this study was to examine differences in military and service separation experiences by sexual orientation among a large representative sample of United States service members and veterans. METHODS: Survey data from the 2016 Millennium Cohort Study follow-up questionnaire were used to assess sexual orientation and multiple outcomes of interest: military experiences (morale, feelings about the military, missed workdays) and service separation experiences (reasons for separation, post-separation employment). The associations between sexual orientation (LGB versus heterosexual) and each of these outcomes were evaluated in a series of adjusted logistic regression models, stratified by sex when interactions were observed. RESULTS: Of the 99,599 participants, 3.4% identified as LGB. In adjusted models, LGB service members had significantly higher odds than heterosexual service members of feeling: unimpressed by the quality of unit leadership, unsupported by the military, and negative about the military overall. Bisexual women were more likely than heterosexual women to feel less unit camaraderie; both gay and bisexual men felt less camaraderie than heterosexual men. LGB veterans were more likely than heterosexual peers of the same sex to separate from service due to unplanned administrative reasons. Compared to heterosexual women, lesbian and bisexual women were more likely to separate from service due to dissatisfaction with promotions/pay and disability/medical reasons, while bisexual women specifically separated due to dissatisfaction with leadership and incompatibility with the military. Gay and bisexual men also reported separating due to incompatibility with the military, but only bisexual men were more likely to report separating due to disability/medical reasons compared to heterosexual men. CONCLUSIONS: Less positive military- and separation-specific experiences disproportionately affected LGB service members in this study. Promoting inclusion and increasing support for LGB service members may improve satisfaction with military service and retention.

The Millennium Cohort Study: The first 20 years of research dedicated to understanding the long-term health of US Service Members and Veterans.

PURPOSE: The Millennium Cohort Study, the US Department of Defense's largest and longest running study, was conceived in 1999 to investigate the effects of military service on service member health and well-being by prospectively following active duty, Reserve, and National Guard personnel from all branches during and following military service. In commemoration of the Study's 20th anniversary, this paper provides a summary of its methods, key findings, and future directions. METHODS: Recruitment and enrollment of the first 5 panels occurred between 2001 and 2021. After completing a baseline survey, participants are requested to complete follow-up surveys every 3-5 years. RESULTS: Study research projects are categorized into 3 core portfolio areas (psychological health, physical health, and health-related behaviors) and several cross-cutting areas and have culminated in more than 120 publications to date. For example, some key Study findings include that specific military service-related factors (e.g., experiencing combat, serving in certain occupational subgroups) were associated with adverse health-related outcomes and that unhealthy behaviors and mental health issues may increase following the transition from military service to veteran status. CONCLUSIONS: The Study will continue to foster stakeholder relationships such that research findings inform and guide policy initiatives and health promotion efforts.

Prevalence and predictors of insomnia and sleep medication use in a large tri-service US military sample.

OBJECTIVE: The presence of insomnia in the general military population is not well known. This study aimed to determine the prevalence of probable clinical insomnia and identify factors leading to new-onset insomnia and/or sleep medication use in a large military population. DESIGN: Cross-sectional and longitudinal analyses of a prospective cohort study. PARTICIPANTS: A tri-service US military and veteran cohort (sample range 99,383-137,114). MEASUREMENTS: Participants were surveyed in 2013 (Time 1 [T1]) and 2016 (Time 2 [T2]) using the clinically validated Insomnia Severity Index. The prevalence of insomnia and sleep medication use was quantified at both times. Multivariable models identified military factors associated with new-onset insomnia and/or sleep medication use while adjusting for covariates. RESULTS: The prevalence of insomnia at T1 and T2 was 16.3% and 11.2%, respectively. New-onset insomnia at T2 was reported by 6.0% of participants screening negative at T1; risk factors included Army service, combat deployment experience, and separation from military service. The prevalence of sleep medication use at T1 and T2 was 23.1% and 25.1%, respectively. Sleep medication use at T2 was newly-reported by 17.1% of participants not reporting sleep medication use at T1; risk factors included number of deployments and having a healthcare occupation. CONCLUSIONS: The prevalence of probable clinical insomnia in this large general military population is within the range of previous reports in military and civilian populations. Certain military factors that predict new-onset insomnia and/or sleep medication use should be considered when designing and implementing sleep interventions in military populations.

Understanding susceptibility to e-cigarettes: A comprehensive model of risk factors that influence the transition from non-susceptible to susceptible among e-cigarette naïve adolescents.

The primary objective of this study was to identify risk factors associated with becoming susceptible to e-cigarette use over the course of a year among e-cigarette-naive adolescents considering a comprehensive model of risk factors (risk perceptions, social influences and norms, affective risk factors, and other behavioral risk factors). Data came from the Texas Adolescent Tobacco and Marketing Surveillance system (TATAMS), a longitudinal cohort study of students who were in the 6th, 8th, and 10th grades (n = 3907) during the 2014-2015 academic year. Weighted generalized linear mixed models assessed multiple predictors' associated with the transition to susceptibility to e-cigarettes at 12 months. Among 6th graders, family influence, use of other substances, and positive affect were important. Adolescents transitioning from 8th grade to high school presented the greatest number of risk factors (e.g., social and normative influences). Only sensation seeking increased the risk of susceptibility to e-cigarettes among 10th graders. Overall, by grade level, incidence of susceptibility to e-cigarettes at 12 months did not vary, but risk factor profiles varied substantially.

Adolescent Tobacco Uptake and Other Substance Use: A Latent Class Analysis.

Objective: The purpose of this study was to identify patterns of tobacco uptake and other substance use, from early to late adolescence. Methods: We used weighted latent class analysis, conducted separately for 7th, 9th, and 11th graders, to assess patterns of susceptibility, ever and current use of combustible tobacco and e-cigarettes, and other substance use (ie, current alcohol, binge drinking, and marijuana). Data were from Wave 3 of the Texas Adolescent Tobacco and Marketing Surveillance System (n = 2733; N = 461,069), collected in fall 2015. Multinomial regression was used to examine differences in class membership by demographic factors. Results: Two latent classes were identified in 7th grade, 3 classes in 9th grade, and 4 classes in 11th grade models. In each grade, classes included both a "no risk" and a "tobacco susceptible" class. For 9th grade, there was an additional "tobacco ever use" class, and 11th grade had the same additional class as well as an "all products use" class. Conclusion: Distinct patterns of polysubstance use emerged as grade level increased, supporting a stage-sequential model of onset and progression across developmental age groups. Future research can examine other factors affecting transitions across these stages.

Measurement and predictive value of susceptibility to cigarettes, e-cigarettes, cigars, and hookah among Texas adolescents.

Susceptibility to cigarette smoking, defined as the lack of a firm commitment not to smoke in the future, begins in childhood and is a phase in the transition from never to ever use of cigarettes. While a consistent and validated predictor of cigarette use, little research has assessed whether the susceptibility construct applies equally well across other tobacco products. Baseline data were collected in 2014-2015 from a representative sample of (n = 2844) middle and high school students in five counties surrounding the four largest cities in Texas, (49% female and mean age 13.13 years, with subsequent waves at 6, 12, and 18 months. Confirmatory factor analysis examined the appropriateness of a three-item susceptibility measure (product-specific curiosity, intention to use, and peer influence) across product types and ethnic groups (Hispanic versus non-Hispanic). Logistic regression examined whether product specific susceptibility at baseline predicted future product initiation. At baseline, 11.5%, 17.0%, 17.4% and 29.4%, of adolescent never users were susceptible to cigars, cigarettes, hookah and e-cigarettes, respectively; significantly more Hispanic than non-Hispanic adolescents were susceptible to e-cigarettes (32.4% versus 26%, p < 0.01) and cigarettes (19.9% versus 13.9%, p < 0.05). Product-specific items were significantly and consistently associated with the respective underlying susceptibility product construct and across ethnic groups (p < 0.001 for all). Susceptibility to e-cigarettes (AOR = 2.28-6.64) or any combustible product (cigarettes, hookah, cigars; AOR = 3.38-5.20) significantly predicted subsequent ever use. This study confirms the appropriateness of the susceptibility construct across four tobacco product types and ethnic groups, and the utility of susceptibility in predicting future product use among adolescents.

Perceived Weight and Bullying Victimization in Boys and Girls.

BACKGROUND: Research suggests that perceived weight poses separate risks from objective weight on adolescents' risks of being bullied. We examined if the prevalence of bullying victimization differed by perceived and objective weight status, and how these associations varied by sex. METHODS: Data were analyzed for 6716 8th and 11th graders from the School Physical Activity and Nutrition project, a Texas statewide survey of public school students. Participants reported demographics, bullying victimization, and weight perceptions. Height and weight were measured. RESULTS: In the last 6 months, 10.8% of students reported being bullied. Nearly 70% of normal weight and overweight and 50% of obese adolescents perceived themselves as weighing the right amount. Perceiving oneself as weighing too little or too much was significantly associated with increased bullying victimization (p < .05 for both), whereas objective weight was not. Statistical interactions between perceived weight and sex were significantly associated with victimization (p < .05) among boys only; boys who perceived themselves as weighing too little had higher predicted probabilities of victimization. CONCLUSIONS: Perceived weight may play a greater role in bullying victimization than objective weight, especially among boys. Interventions to prevent bullying should consider adolescents' self-perceptions of weight to effectively identify those at greater risk for victimization.

Self-reported use of nutrition labels to make food choices is associated with healthier dietary behaviours in adolescents.

OBJECTIVE: The study aimed to examine nutrition label use and dietary behaviours among ethnically diverse middle- and high-school students, in Texas, USA. DESIGN: The School Physical Activity and Nutrition (SPAN) survey is a cross-sectional statewide study using a self-administered questionnaire to assess nutrition and physical activity behaviours. Height and weight measurements were used to determine BMI. Multivariable logistic regression was used to determine associations between nutrition label use and dietary behaviours, with gender, grade, ethnicity, BMI, parent education, socio-economic status and nutrition knowledge as covariates. SETTING: Participants from 283 schools, weighted to represent Texas youth. SUBJECTS: SPAN 2009-2011 included 6716 8th and 11th graders (3465 girls and 3251 boys). The study population consisted of 39·83 % White/Other, 14·61 % African-American and 45·56 % Hispanic adolescents; with a mean age of 14·9 years, and 61·95 % at a healthy weight, 15·71 % having overweight and 22·34 % having obesity. RESULTS: Adolescents who did not use nutrition labels had 1·69 times greater odds of consuming ≥1 sugary beverages/d (P<0·05). Adolescents who used nutrition labels had 2·13 times greater odds of consuming ≥1 fruits and vegetables/d (P<0·05). Adolescents who used nutrition labels had significantly higher healthy eating scores than those who did not (P<0·001). For every 1-point increase in nutrition knowledge, adolescents had 1·22 greater odds of using nutrition labels. CONCLUSIONS: Nutrition label use is associated with healthier dietary behaviours in adolescents. Intervention strategies for youth should include efforts to teach adolescents to use labels to make healthy food choices.

Educational outcomes associated with childhood obesity in the United States: cross-sectional results from the 2011-2012 National Survey of Children's Health.

BACKGROUND: Past research examining the effects of childhood obesity has largely focused on its projected effects into adulthood. However, there is emerging evidence that childhood obesity may have more immediate effects on school-related outcomes. We examine a range of educational attainment indicators to examine the possible pathway between obesity status and academic performance, while investigating the proximal effects of childhood obesity on health and utilization of health services, and whether these variables attenuate the relationship between obesity status and educational outcomes. METHODS: Data for the current study come from the 2011-2012 National Survey of Children's Health, which details the impacts of childhood obesity on a range of outcomes among a nationally representative sample of children and adolescents aged 10-17 years (N=45,255). Educational outcomes (school absences, school problems, repeating a grade and school engagement) were modeled by logistic regression as a function of BMI, overall health status, health care utilization, and a range of sociodemographic variables. RESULTS: BMI status was significantly associated with all educational outcomes (p<0.001 for all), overall health status (p<0.001), and health care utilization (p=0.016). Prior to adjustment for covariates, obese children were significantly more likely to have school absences and school problems, to repeat a grade, and to have lower school engagement than non-overweight children. After adjustment for sociodemographic and health/healthcare variables, these outcomes remained significant for all but repeating a grade. The odds of having school problems, repeating a grade, and low school engagement that were associated with obesity were attenuated by the addition of sociodemographic variables into the model, while the addition of health and health care variables in the model decreased the odds of school absences. CONCLUSIONS: This study provides evidence that increased weight status in children is associated with poorer educational outcomes. While recognizing that these are cross-sectional data, we suggest that 1) health-related and sociodemographic factors should be a focus point of intervention, and 2) a socio-structural approach including Coordinated School Health intervention is crucial to reducing childhood obesity and improving educational outcomes in this population.

Intergenerational transfer of smoking across three generations and forty-five years.

OBJECTIVES: Although many have examined the linkages between smoking behaviors across 2 generations, few have examined these linkages among 3 generations. METHODS: U.S. population representative data for 3 generations are drawn from the Panel Study of Income Dynamics (PSID) in order to examine whether smoking behaviors are passed down from generation to generation and the magnitude of the influence of smoking behaviors across generations (N = 830). RESULTS: Results indicate direct linkages between both grandparent (G1) and parent (G2) smoking (OR = 4.53; 95% CI = 2.57-7.97) and parent (G2) and young adult offspring (G3) smoking (OR = 2.91; 95% CI = 1.60-5.31). Although the direct link between grandparent (G1) and grandchildren (G3) was not significant (OR = 2.25; 95% CI = 0.96-5.23, p < .10), mediation analyses reveal that the link between G3 and G1 smoking is significantly mediated by G2 smoking. CONCLUSIONS: Regardless of generation, parent smoking behavior has a direct influence on offspring smoking behavior. The link between grandparent (G1) and grandchild (G3) smoking is mediated by parent (G2) smoking, suggesting that smoking behavior is passed from one generation to the next generation and in turn to the next generation.

Exposure to pro-tobacco messages and smoking status among Mexican origin youth.

Though several studies have found a positive relationship between exposure to tobacco advertising and/or promotional marketing and smoking status among youth, few have examined these relationships specifically for youth of Mexican origin. The current analysis examines the relationship between perceived exposure to pro-tobacco messages and progression through the smoking continuum from trying to repeated use in a cohort of Mexican origin youth ages 14-19. Data were collected via personal in-home interviews at two time points-in 2008-2009 and 2010-2011 (N = 942). Smoking status, exposure to pro-tobacco messages from five major media sources, demographic variables and established risk factors for adolescent smoking were measured at both waves. Data were analyzed using Pearson's Chi square tests, ANOVA, and multinomial logistic regression. Adolescent perception of the number of pro-tobacco messages seen in 2008-2009 was unrelated to smoking less than one cigarette assessed in 2010-2011. However, having seen a higher number of pro-tobacco messages was significantly associated with being more likely to have smoked more than one cigarette (OR = 1.21; 95% CI 1.03-1.42) controlling for demographic factors and known psychosocial risk factors of smoking behavior. Results suggest that the more pro-tobacco messages Mexican origin youth are able to recall, the further their progression through the smoking trajectory a year later. These youth are clearly susceptible to pro-tobacco messaging, and our results underscore the need to restrict all forms of messaging that promote tobacco use.