Nutrition and Food Security Among Veterans: Operationalizing Nutritional Functioning.

OBJECTIVE: To assess injured military veterans' experiences, beliefs, and daily physical and psychosocial functioning in relation to food and nutrition. DESIGN: We used a convergent mixed-methods study design and the International Classification of Functioning, Disability, and Health to operationalize the core constructs and influencing factors related to physical and psychosocial functioning, food, and nutrition. SETTING: Three Veterans Affairs polytrauma rehabilitation centers. PARTICIPANTS: Veterans who served in the United States military on or after September 11, 2001, and whose medical diagnoses met the criteria for polytrauma; at least 1 mild traumatic brain injury and at least 1 associated comorbidity (eg, posttraumatic stress disorder, chronic musculoskeletal pain, vestibular disturbances), for a total N of 43. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Themes from survey responses and semistructured interview data were pooled into core constructs and influencing factors. RESULTS: Thirty-seven veterans completed all surveys and participated in recorded interviews. Based on qualitative and quantitative data, veterans' relation to food and nutrition (ie, nutritional functioning) was found to be characterized by 5 core constructs, including food background, nutrition knowledge, meal aptitude, resource navigation, and navigation to/of food spaces. Nutritional functioning was found to be shaped by 5 influencing factors, including injuries and health conditions, ideological and cultural exposures, relations, current beliefs, and current behaviors. CONCLUSIONS: Nutritional functioning (food background, nutrition knowledge, meal aptitude, resource navigation, navigation to/of food spaces) among injured veterans is complex and shaped by multiple physical, psychosocial, economic, and cultural factors.

Microbial Diversity and Community Structures Among Those With Moderate to Severe TBI: A United States-Veteran Microbiome Project Study.

OBJECTIVE: To evaluate the association between distal moderate/severe traumatic brain injury (TBI) history and the human gut microbiome. SETTING: Veterans Affairs Medical Center. PARTICIPANTS: Veterans from the United States-Veteran Microbiome Project (US-VMP). Veterans with moderate/severe TBI (n = 34) were compared with (1) Veterans with a history of no TBI (n = 79) and (2) Veterans with a history of no TBI or mild TBI only (n = 297). DESIGN: Microbiome analyses from 16S rRNA gene sequencing with gut microbiota function inferred using PICRUSt2. MAIN MEASURES: α-Diversity and ß-diversity of the gut microbiome, as well as taxonomic and functional signatures associated with moderate/severe TBI. RESULTS: There were no significant differences in gut bacterial α- and ß-diversity associated with moderate/severe TBI status. No differentially abundant taxa were identified when comparing samples from moderate/severe TBI to those with no TBI or no TBI/mild TBI. CONCLUSION: Results suggest that moderate/severe TBI-related changes to the gut microbiome do not persist for years postinjury.

Nutritional status and body composition in patients with peripheral arterial disease: A cross-sectional examination of disease severity and quality of life.

Nutritional and body weight recommendations for cardiovascular diseases are well established, yet there are no equivalent guidelines for peripheral arterial disease (PAD). This cross-sectional study measured the prevalence of cardiovascular-related nutritional and body composition risk factors in sixty PAD patients and their association with PAD severity. A diet that exceeds daily recommended intake of fat and that falls short of recommended intakes of fiber, folate, and vitamin D was associated with increased leg pain and walking difficulty. Increased body fat and waist circumference were associated with diminished walking ability and poorer psychosocial quality of life. Future prospective investigations are merited to inform both PAD clinical care and disease management guidelines.

Association of homelessness and diet on the gut microbiome: a United States-Veteran Microbiome Project (US-VMP) study.

Military veterans account for 8% of homeless individuals living in the United States. To highlight associations between history of homelessness and the gut microbiome, we compared the gut microbiome of veterans who reported having a previous experience of homelessness to those from individuals who reported never having experienced a period of homelessness. Moreover, we examined the impact of the cumulative exposure of prior and current homelessness to understand possible associations between these experiences and the gut microbiome. Microbiome samples underwent genomic sequencing and were analyzed based on alpha diversity, beta diversity, and taxonomic differences. Additionally, demographic information, dietary data, and mental health history were collected. A lifetime history of homelessness was found to be associated with alcohol use disorder, substance use disorder, and healthy eating index compared to those without such a history. In terms of differences in gut microbiota, beta diversity was significantly different between veterans who had experienced homelessness and veterans who had never been homeless (P = 0.047, weighted UniFrac), while alpha diversity was similar. The microbial community differences were, in part, driven by a lower relative abundance of Akkermansia in veterans who had experienced homelessness (mean; range [in percentages], 1.07; 0-33.9) compared to veterans who had never been homeless (2.02; 0-36.8) (P = 0.014, ancom-bc2). Additional research is required to facilitate understanding regarding the complex associations between homelessness, the gut microbiome, and mental and physical health conditions, with a focus on increasing understanding regarding the longitudinal impact of housing instability throughout the lifespan.IMPORTANCEAlthough there are known stressors related to homelessness as well as chronic health conditions experienced by those without stable housing, there has been limited work evaluating the associations between microbial community composition and homelessness. We analyzed, for the first time, bacterial gut microbiome associations among those with experiences of homelessness on alpha diversity, beta diversity, and taxonomic differences. Additionally, we characterized the influences of diet, demographic characteristics, military service history, and mental health conditions on the microbiome of veterans with and without any lifetime history of homelessness. Future longitudinal research to evaluate the complex relationships between homelessness, the gut microbiome, and mental health outcomes is recommended. Ultimately, differences in the gut microbiome of individuals experiencing and not experiencing homelessness could assist in identification of treatment targets to improve health outcomes.

Association between modifiable social determinants and mental health among post-9/11 Veterans: A systematic review.

Introduction: As U.S. Veterans reintegrate from active duty to civilian life, many are at risk for negative modifiable social determinants of health. The prevalence of mental health conditions among Veterans is also high. Awareness of the associations between these two factors is growing. This systematic review provides a comprehensive analysis of the current state of knowledge of the associations between modifiable social determinants and mental health among U.S. Veterans. Methods: The authors systematically searched four databases and identified 28 articles representing 25 unique studies that met inclusion criteria. Findings from the studies were extracted and synthesized on the basis of modifiable social determinants. Study quality and risk of bias were assessed using the Methodological Quality Questionnaire. Results: The studies identified in the systematic review examined three modifiable social determinants of health: 1) housing stability, 2) employment and finances, and 3) social support. Although the lack of validity for measures of housing stability, employment, and finances compromised study quality, the overall evidence suggests that Veterans with access to supportive social determinants had better mental health status. Evidence was particularly robust for the association between strong social support and lower symptoms of posttraumatic stress disorder. Discussion: Current evidence suggests the need to consider modifiable social determinants of health when designing mental health interventions. However, more research encompassing a wider range of modifiable social determinants such as food security, education, and transportation and using comprehensive methods and validated instruments is needed. Future research also needs to intentionally include Veterans from diverse racial-ethnic groups.

Food desert residence has limited impact on veteran fecal microbiome composition: a U.S. Veteran Microbiome Project study.

IMPORTANCE: Social and economic inequities can have a profound impact on human health. The inequities could result in alterations to the gut microbiome, an important factor that may have profound abilities to alter health outcomes. Moreover, the strong correlations between social and economic inequities have been long understood. However, to date, limited research regarding the microbiome and mental health within the context of socioeconomic inequities exists. One particular inequity that may influence both mental health and the gut microbiome is living in a food desert. Persons living in food deserts may lack access to sufficient and/or nutritious food and often experience other inequities, such as increased exposure to air pollution and poor access to healthcare. Together, these factors may confer a unique risk for microbial perturbation. Indeed, external factors beyond a food desert might compound over time to have a lasting effect on an individual's gut microbiome. Therefore, adoption of a life-course approach is expected to increase the ecological validity of research related to social inequities, the gut microbiome, and physical and mental health.

Implementing Nutrition Education Programs in Congregate Dining Service Settings: A Scoping Review.

BACKGROUND AND OBJECTIVES: Nutrition education programs implemented in congregate dining service (CDS) settings have the potential to improve healthy eating behaviors among older adult populations. However, little is understood about the types of nutrition education programs that are implemented at CDS sites and the factors that impede or promote implementation efforts. The purpose of this scoping review was to examine the characteristics of CDS nutrition education programs, barriers and supports to program implementation, and opportunities to enhance implementation of programming. RESEARCH DESIGN AND METHODS: We adopted a scoping review methodology to assess the relevant literature published between January 2000 and 2020 by accessing CINAHL, SocINDEX, MEDLINE, AgeLine, and Academic Search Complete. RESULTS: We identified 18 studies that met our inclusion criteria. The majority of nutrition education programs were led by trained facilitators, included the use of interactive activities, and also incorporated written or video materials. Programs that were adapted to the needs of older participants were perceived as supports to implementation whereas participants' needs and resources (e.g., lack of resources and lower health literacy) were occasionally found to limit the effective implementation of programming. DISCUSSION AND IMPLICATIONS: As the older adult population continues to access CDS sites to address their health and nutritional needs, purposeful efforts are needed to examine the specific approaches that can support nutrition education program implementation. Future opportunities lie in assessing strategies that are effective for mitigating barriers to implementing nutrition education programming in the CDS setting.

Food Insecurity and Food Worries During the COVID-19 Pandemic: A Point-In-Time Study of Injured United States Veterans.

US Military Veterans experience higher rates of food insecurity compared to civilians, but the impact of the COVID-19 pandemic on Veterans is unclear. We conducted a nationwide survey of injured post-9/11 Veterans' food security, Coronavirus exposure, and nutrition habits. Of 193 Veterans, 63 (32.6%) were food insecure. Food insecurity was associated with Hispanic ethnicity (p = 0.02), prior homelessness (p = 0.003), combat service (p < 0.0001), and food-related worries (p = 0.003). Food insecure Veterans were more likely to report anxiety about stigma related to COVID-19 infection (p = 0.007). Nutrition assistance initiatives should attend to emergent psychosocial factors, beyond well-established economic factors, that increase risk for food insecurity.

Rationale, design, and methods: A randomized placebo-controlled trial of an immunomodulatory probiotic intervention for Veterans with PTSD.

Background: United States military Veterans from recent conflicts are experiencing symptoms related to posttraumatic stress disorder (PTSD). Many Veterans are resistant to conventional health and mental health interventions (e.g., medication, psychotherapy). Alternative treatment approaches are needed. An underlying feature of PTSD is exaggerated inflammation, both peripherally and in the central nervous system. This inflammation is thought to play an important role in the vulnerability to, aggravation of, and persistence of PTSD symptoms. Therefore, an innovative intervention strategy would be the use of immunoregulatory/anti-inflammatory probiotics to reduce inflammation. Here we describe the rationale, design, and methods of a randomized placebo-controlled trial (RCT) of Lactobacillus rhamnosus GG (LGG; ATCC 53103) for posttraumatic stress disorder (PTSD). Methods: This is a Phase IIa trial of LGG for United States military Veterans with PTSD, using a longitudinal, double-blind, randomized placebo-controlled design. The primary outcome measure is plasma concentration of high-sensitivity C-reactive protein. Conclusion: Despite the fact that symptoms associated with PTSD can be disabling, individuals living with this trauma-related disorder have limited options in terms of evidence-based interventions. Recent research efforts aimed at highlighting the biological mechanisms of PTSD suggest that increased inflammation and altered autonomic nervous system activity may be treatment targets, and that immunoregulatory probiotics, such as LGG, have the potential to decrease trauma-induced inflammatory responses, as well as associated symptoms. This manuscript describes the best powered human subjects Phase IIa trial, to date, of a probiotic intervention for those living with PTSD.

Characterization of the gut microbiota among Veterans with unique military-related exposures and high prevalence of chronic health conditions: A United States-Veteran Microbiome Project (US-VMP) study.

The gut microbiome is impacted by environmental exposures and has been implicated in many physical and mental health conditions, including anxiety disorders, affective disorders, and trauma- and stressor-related disorders such as posttraumatic stress disorder (PTSD). United States (US) military Veterans are a unique population in that their military-related exposures can have consequences for both physical and mental health, but the gut microbiome of this population has been understudied. In this publication, we describe exposures, health conditions, and medication use of Veterans in the US Veteran Microbiome Project (US-VMP) and examine the associations between these characteristics and the gut microbiota. This cohort included 331 US Veterans seeking healthcare with the Veterans Health Administration who were 83% male with an average (±SD) age of 47.6 â€‹± â€‹13.4 years. The cohort displayed a high prevalence of PTSD (49.8%) and history of traumatic brain injuries (76.1%), and high current use of prescription medications (74.9%) to treat various acute and chronic conditions. We observed significant associations between the gut microbiota composition and gastroenteritis, peripheral vascular disease (PVD), bipolar disorders, symptoms of severe depression based on the Beck Depression Inventory, stimulant and opioid use disorders, beta-blockers, serotonin and norepinephrine reuptake inhibitor antidepressants, diabetes medications, and proton pump inhibitors. Many of the Veteran characteristics examined were associated with altered relative abundances of specific taxa. We found that PVD and cardiovascular disease were associated with lower microbiota diversity in the gut (i.e., α-diversity), while supplemental vitamin use was associated with higher α-diversity. Our study contributes novel insights as to whether the unique exposures of Veterans in this cohort correlate with gut microbiota characteristics and, in line with previous findings with other population-level studies of the microbiome, confirms associations between numerous health conditions and medications with the gut microbiome.

Evaluation of an Immunomodulatory Probiotic Intervention for Veterans With Co-occurring Mild Traumatic Brain Injury and Posttraumatic Stress Disorder: A Pilot Study.

Background: US military Veterans returned from Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) with symptoms associated with mild traumatic brain injury [mTBI; i.e., persistent post-concussive (PPC) symptoms] and posttraumatic stress disorder (PTSD). Interventions aimed at addressing symptoms associated with both physical and psychological stressors (e.g., PPC and PTSD symptoms) are needed. This study was conducted to assess the feasibility, acceptability, and safety of a probiotic intervention, as well as to begin the process of evaluating potential biological outcomes. Methods: A pilot randomized controlled trial was implemented among US military Veterans from recent conflicts in Iraq and Afghanistan. Those enrolled had clinically significant PPC and PTSD symptoms. Participants were randomized to intervention (Lactobacillus reuteri DSM 17938) or placebo supplementation (daily for 8 weeks +/- 2 weeks) at a 1:1 ratio, stratified by irritable bowel syndrome status. Thirty-one Veterans were enrolled and randomized (15 to the placebo condition and 16 to the probiotic condition). Results: Thresholds for feasibility, acceptability, and safety were met. Probiotic supplementation resulted in a decrease in plasma C-reactive protein (CRP) concentrations relative to the placebo group that approached statistical significance (p = 0.056). Although during the Trier Social Stress Test (TSST; administered post-supplementation) no between-group differences were found on a subjective measure of stress responsivity (Visual Analog Scale), there was a significantly larger increase in mean heart beats per minute between baseline and the math task for the placebo group as compared with the probiotic group (estimated mean change, probiotic 5.3 [95% Confidence Interval: -0.55, 11.0], placebo 16.9 [11.0, 22.7], p = 0.006). Conclusions: Findings from this trial support the feasibility, acceptability, and safety of supplementation with an anti-inflammatory/immunoregulatory probiotic, L. reuteri DSM 17938, among Veterans with PPC and PTSD symptoms. Moreover, results suggest that CRP may be a viable inflammatory marker of interest. A larger randomized controlled trial aimed at measuring both biological and clinical outcomes is indicated. Clinical Trial Registration: ClinicalTrials.gov, Identifier NCT02723344.

Mental Illness, Not Obesity Status, is Associated with Food Insecurity Among the Elderly in the Health and Retirement Study.

OBJECTIVES: Food insecurity, limited or uncertain access to adequate nutrition, is an increasingly recognized determinant of health outcomes and is often associated with having obesity. It is unclear, however, if this association persists in elderly populations. METHODS: We conducted a cross-sectional study of 2868 participants' aged 65+ years from the Health and Retirement Study. Multivariate logistic regression was used to assess associations between food insecurity and body mass index, demographic characteristics, psychiatric history, and medical history. RESULTS: Participants with overweight/obesity had a higher prevalence of food insecurity than leaner counterparts, however, weight status was not a significant predictor of food insecurity after multivariate adjustment. Instead, mental illness, current smoking status, and non-White race were all independently associated with food insecurity. DISCUSSION: Beyond financial status, health care providers are encouraged to use these characteristics to identify elderly patients that may be at risk of food insecurity.

Mental illness and obesity among Veterans undergoing percutaneous coronary intervention: Insights from the VA CART program.

Mental illness and obesity are highly prevalent in patients with coronary disease and are frequently comorbid. While mental illness is an established risk factor for major adverse cardiac and cerebrovascular events (MACCEs), prior studies suggest improved outcomes in people with obesity. It is unknown if obesity and mental illness interact to affect cardiac outcomes or if they independently influence MACCE. We identified 55 091 patients undergoing percutaneous coronary intervention (PCI) between 2009 and 2014, using the Veterans Affairs (VA) Clinical Assessment Reporting and Tracking (CART) program. Cox methods were used to assess the risk of MACCE by weight status and psychiatric diagnosis, and assessed for interaction. Compared to normal weight status, higher weight was associated with reduced MACCE events after PCI (mean follow-up of 2 years) for both stable angina and acute coronary syndromes (ACSs; reduction of >13% in stable angina, >17% in ACS; P < 0.01 for both after adjustment). Having a non-substance abuse mental illness diagnosis increased risk of MACCE compared to patients without mental illness in stable angina over 17%; P < 0.05, but not in ACS. When analysed for interaction, obesity and mental illness did not significantly impact MACCE over their independent influences. These results suggest that mental illness along with weight status have significant impact on MACCE, post-PCI. Clinicians should be aware of patients' mental health status as a significant cardiovascular risk factor after PCI, independent of weight status.

Depression in patients with peripheral arterial disease: A systematic review.

OBJECTIVES: The association between cardiovascular disease and depression is well-established. Peripheral arterial disease arises from atherosclerosis like other cardiovascular disease, but unlike other cardiovascular disease, it impairs ambulation and lower extremity function. Given peripheral arterial disease's unique characteristics and underrepresentation in mental health research, we aimed to: (a) assess the prevalence of depression or depressive symptoms among peripheral arterial disease patients compared to coronary artery disease rates, (b) assess whether an independent association between peripheral arterial disease and depression exists, and (c) identify associated factors that may be targeted for intervention. DESIGN: This study was based on a systematic review. MATERIALS AND METHODS: Electronic databases were searched to identify studies that examined peripheral arterial disease and depression or depressive symptoms. Methodological quality was assessed using the Newcastle-Ottawa Scale. RESULTS: We identified 28 studies. Prevalence of depression or depressive symptoms ranged from 11-48% in 12 cross-sectional studies, and from 3-36% in 16 longitudinal studies, which is comparable to reported coronary artery disease rates. Depressed peripheral arterial disease patients were more likely to be female, African American, and have more severe peripheral arterial disease symptoms and more compromised physical function compared to non-depressed patients. There is evidence to suggest that depression exerts a negative influence on walking ability and physical function independently of peripheral arterial disease. CONCLUSIONS: There is a critical need to address depression in peripheral arterial disease patients, particularly those with characteristics that place them at increased risk. Vascular care providers appear to be the primary contact for assessing depressive symptoms, and once identified, integrated mental health providers may intervene to prevent the worsening of both depression and peripheral arterial disease.

Recruiting older patients with peripheral arterial disease: evaluating challenges and strategies.

Peripheral arterial disease (PAD) is a group of syndromes characterized by chronic and progressive atherosclerosis with a high burden of physical disability and cardiovascular morbidity and mortality. Recruiting patients for clinical research is therefore challenging. In this article, we describe and evaluate our methods for recruiting participants for a cross-sectional feasibility study of PAD, nutritional status, and body composition. We used convenience and purposive sampling approaches to identify potential participants. Between May 2012 and April 2013, 1,446 patients were identified, and 165 patients (11.4%) responded to recruitment requests. The final enrollment was 64 participants (64/1,446; 4.4%), and four subjects (6.3%) subsequently withdrew from the study. Recruiting PAD patients presents a variety of challenges, due largely to the burdens of living with coexistent illnesses, and patients' reluctance or inability to travel for research. In this article, we delineate suggestions for improving the efficacy of recruitment methods in future PAD studies.

The role of nutrition and body composition in peripheral arterial disease.

Peripheral arterial disease (PAD) has not been as extensively investigated as other cardiovascular diseases. However, the available data suggest that nutrition-based treatment strategies have the potential to reduce the cost-economic burden of PAD substantially. Abdominal obesity is associated with PAD and prospective and cross-sectional studies have shown that a low dietary intake of folate and reduced synthesis of vitamin D are associated with an increased risk of PAD and severe walking impairment in patients who have the disease. However, dietary patterns that are associated with decreased cardiovascular risk might protect against PAD. A small number of clinical trials have provided evidence that increased intakes of niacin and insoluble fiber might be associated with decreased levels of LDL cholesterol and thrombogenic biomarkers, as well as increased serum levels of HDL cholesterol in patients with PAD. However, little evidence that antioxidants, vitamins B(6) and B(12), or essential fatty acid supplements improve clinical outcomes in these patients exists. Overall, data on the effects of nutrition, body composition, and nutritional supplementation on the risk, progression, and prognosis of PAD are scarce. Further research into these areas is required to allow the development of evidence-based nutritional guidelines for the prevention and treatment of the disease.

Omega-3 fatty acids and incident type 2 diabetes: the Singapore Chinese Health Study.

BACKGROUND: The role of omega-3 (n-3) fatty acids (FAs) in the development of type 2 diabetes is uncertain, especially with regard to any differential influence of α-linolenic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). OBJECTIVE: The objective was to examine the association between total omega-3 FAs, marine omega-3 (EPA, DHA), nonmarine omega-3 (ALA), and omega-6 (n-6) FAs and omega-6:omega-3 ratio and risk of type 2 diabetes in a Chinese population in Singapore. DESIGN: The analysis included 43,176 Chinese men and women free of chronic disease, aged 45-74 y, in the Singapore Chinese Health Study. Baseline data collection occurred between 1993 and 1998, with follow-up interviews between 1999 and 2004. Cox regression models were used to examine the associations between FA intakes at baseline and risk of developing diabetes. RESULTS: Increased intakes of total omega-3 FAs were inversely associated with diabetes incidence [hazard ratio (HR) for the fifth compared with the first quintile: 0.78; 95% CI: 0.65, 0.94; P for trend = 0.02]. Omega-3 FAs from marine sources were not associated with diabetes risk, whereas nonmarine omega-3 FA intake was strongly associated (HR for the fifth compared with the first quintile: 0.79; 95% CI: 0.67, 0.93; P for trend = 0.004). Omega-6 and omega-6:omega-3 ratio were not associated with incidence of type 2 diabetes. CONCLUSION: Consumption of nonmarine sources (ALA) of omega-3 FAs is associated with a decreased risk of type 2 diabetes in Chinese Singaporeans.