Emotional dysregulation moderates the relation between perceived stress and emotional eating in adolescent military dependents.

OBJECTIVE: Adolescent children of US service members (i.e., military-dependent youth) face unique stressors that increase risk for various forms of disinhibited eating, including emotional eating. Difficulties with adaptively responding to stress and aversive emotions may play an important role in emotional eating. This study examined emotion dysregulation as a potential moderator of the association between perceived stress and emotional eating in adolescent military dependents. METHOD: Participants were military-dependent youth (N = 163, 57.7% female, Mage = 14.5 ± 1.6, MBMI-z = 1.9 ± 0.4) at risk for adult binge-eating disorder and high weight enrolled in a randomized controlled prevention trial. Prior to intervention, participants completed questionnaires assessing perceived stress and emotional eating. Parents completed a questionnaire assessing their adolescent's emotion dysregulation. Moderation analyses were conducted using the PROCESS macro in SPSS and adjusted for theoretically relevant sociodemographic covariates. RESULTS: The interaction between adolescent perceived stress and emotion dysregulation (parent-reported about the adolescent) in relation to adolescent emotional eating was found to be significant, such that higher emotion dysregulation magnified the association between perceived stress and emotional eating (p = .010). Examination of simple slopes indicated that associations between perceived stress and emotional eating were strongest for youth with above-average emotion dysregulation, and non-significant for youth with average or below-average emotion dysregulation. DISCUSSION: Findings suggest that greater emotion dysregulation may increase risk for emotional eating in response to stress among military-dependent youth at risk for binge-eating disorder or high weight. Improving emotion regulation skills may be a useful target for eating disorder prevention among youth who are at risk for emotional eating. PUBLIC SIGNIFICANCE: Prior research has shown that adolescent military dependents are at increased risk for eating disorders and high weight. The current study found that emotion dysregulation moderated the relationship between perceived stress and emotional eating among military-dependent youth. There may be clinical utility in intervening on emotion regulation for adolescent dependents at particular risk for emotional eating and subsequent eating disorders.

The Relationship Between Anxiety, Coping, and Disordered-Eating Attitudes in Adolescent Military-Dependents at High-Risk for Excess Weight Gain.

Adolescent military-dependents are an understudied population who face unique stressors due to their parents' careers. Research suggests that adolescent military-dependents report more anxiety and disordered-eating than their civilian counterparts. While anxiety symptoms predict the onset and worsening of disordered-eating attitudes, the mechanisms underlying this relationship remain unclear. One factor that may underlie this relationship, and be particularly relevant for military-dependent youth, is coping. Therefore, we examined adolescent military-dependents (N=136; 14.5±1.5 years; 59.6% female; BMI-z: 1.9±0.4) who were at-risk for adult obesity and binge-eating disorder due to an age- and sex-adjusted BMI ≥ 85th percentile and loss-of-control eating and/or elevated anxiety. Participants completed an interview assessing disordered-eating attitudes and questionnaires on anxiety symptoms and coping strategies at a single time point. Bootstrapping models were conducted to examine the indirect paths between anxiety symptoms and disordered-eating attitudes through five coping subscales (aggression, distraction, endurance, self-distraction, and stress-recognition). Adjusting for relevant covariates, no significant indirect paths through the coping subscales (ps > .05) were found in any models. General coping, non-specific to eating, may not be a pathway between anxiety symptoms and disordered-eating attitudes among adolescents. Future research should examine other potential mediators of this relationship.

Prescriptions of Psychotropic Medications by Providers Treating Children of Military Service Members.

INTRODUCTION: There are approximately 1.5 million U.S. military-dependent children. However, little is known about mental health referrals for these youths. This study sought to examine the type of mental health treatment referrals made by primary care providers for child military-dependent beneficiaries receiving care in the direct (within Military Treatment Facilities) and private care (civilian-fee-for service facilities) sectors of the Military Health System. MATERIALS AND METHODS: A between-subjects, cross-sectional study was performed on children aged 5-18 years old in fiscal years 2011-2015 and enrolled in TRICARE Prime. Study analyses examined specialty ("talk therapy") mental health care and psychotropic medication referrals from TRICARE Prime (the Defense Health Agency-managed health care program) providers for beneficiary children diagnosed with attention-, mood-, anxiety-, or behavior-related disorders in direct versus private sector care. RESULTS: Of 1,533,630 children enrolled in TRICARE Prime (50.03% female), 8.6% (n = 131,393) were diagnosed with a psychological disorder during FY 2011-2015. Most were attention-related (5.2%, n = 79,770), followed by mood (1.7%, n = 25,314), anxiety (1.1%, n = 16,155), and conduct-related diagnoses (0.7%, n = 10,154). Adjusting for age, sex, and sponsor rank, children within direct care diagnosed with attention-related disorders were 1.7 times more likely to receive a prescription for psychotropic medication than those in private sector care, odds ratio (OR) = 1.72, 95% confidence interval (CI): [1.66, 1.77]. Children diagnosed with mood-related disorders in direct care were 2.1 times more likely to receive a prescription for psychotropic medication than those in private sector care, OR = 2.08, 95% CI: [1.96, 2.21]. Across disorders, children who received private sector care were more likely to have a referral specialty mental health ("talk therapy") follow-up (ps < 0.0001). CONCLUSIONS: For attention- and mood-related disorders, but not anxiety- or conduct-related disorders, direct care providers were more likely than private sector care providers to prescribe psychotropic medications. Inconsistencies of provider referrals within and outside of the Military Health System should be elucidated to determine the impact on outcomes.

The Role of the Family Physician in Rural Maternity Care.

Of the 28 million rural women of reproductive age in the United States, ∼7 million of them live in areas of limited access to maternity care. While only 6.7% of Family Physicians currently provide maternity care, they are the only delivering physicians in 27% of rural hospitals. Of the 1.6% of Family Physicians performing cesarean deliveries as a primary surgeon, 57.3% do so in a rural county and 38.6% do so in a county without an obstetrician. Cultivation of the next generation of Family Physicians providing maternity care is essential to prevent further spread of existing maternity care deserts.

Associations among alexithymia, disordered eating, and depressive symptoms in treatment-seeking adolescent military dependents at risk for adult binge-eating disorder and obesity.

PURPOSE: Evidence suggests that difficulties identifying and describing one's feelings, core components of alexithymia, are associated with attitudinal and behavioral symptoms of disordered eating; depressive symptoms also may underlie these associations. Specifically, research indicates that alexithymia is positively related to depressive symptoms, which in turn may promote both disordered-eating attitudes and certain disinhibited-eating behaviors (e.g., emotional eating). Findings also suggest that military-dependent youth with high weight may exhibit elevated depressive symptoms and disordered eating. As such, understanding associations among alexithymia, depressive symptoms, and disordered eating is particularly relevant for this vulnerable population. METHODS: We examined 149 adolescent military dependents (14.4 ± 1.6y; 55.0% female; 20.0% non-Hispanic Black; BMIz: 1.9 ± 0.4) at high risk for binge-eating disorder and obesity in adulthood. Participants completed questionnaires assessing two components of alexithymia (difficulty identifying feelings [DIF] and difficulty describing feelings [DDF]), depressive symptoms, emotional eating, and trait anxiety; disordered-eating attitudes were assessed via semi-structured interview. RESULTS: A series of regression-based models examined indirect relationships of DIF and DDF with disordered-eating attitudes and emotional eating through depressive symptoms. Bootstrapped 95% confidence intervals revealed a significant indirect path from each of the alexithymia components to disordered-eating attitudes via depressive symptoms; indirect paths to emotional eating were non-significant. CONCLUSION: Results support the salience of depressive symptoms in the relationship between alexithymia and disordered-eating attitudes. Future research should utilize prospective designs and explore direct and indirect associations of alexithymia with other disordered-eating behaviors. LEVEL OF EVIDENCE: Level III, evidence obtained from a well-designed cohort study.

Examination of the Interaction between Parental Military-Status and Race among Non-Hispanic Black and Non-Hispanic White Adolescents with Overweight/Obesity.

OBJECTIVES: Adolescent military-dependents experience distinct risk and protective factors, which may necessitate additional clinical considerations. In civilian youth, overweight/obesity is associated with eating, internalizing, and externalizing difficulties, with some studies reporting more difficulties among non-Hispanic White (vs. non-Hispanic Black) youth. It is unknown if these disparities exist among adolescent military-dependents, or between civilian and military-dependent youth. METHODS: Non-Hispanic Black (187 civilian, 38 military-dependent) and non-Hispanic White (205 civilian, 84 military-dependent) adolescents with overweight/obesity (14.7 ± 1.6 years; 73.9% girls; body mass index adjusted for age and sex 1.9 ± 0.5) completed a disordered-eating interview; parents completed a measure assessing their child's internalizing and externalizing difficulties. Multiple linear regressions examined parental military-status as a moderator of the relationship of participant race with eating, internalizing, and externalizing difficulties. RESULTS: White civilian youth with overweight/obesity reported significantly greater disordered-eating than their Black peers (p < .001); there were no other significant racial differences. In all regressions, parental military-status significantly moderated the association between race and each dependent variable (ps < .047). Black military-dependents (vs. civilians) reported more disordered-eating and internalizing difficulties (ps = .01). White military-dependents (vs. civilians) reported fewer externalizing difficulties (p = .01). CONCLUSIONS: Black adolescent military-dependents with overweight/obesity may experience more eating and internalizing difficulties (vs. civilians), a pattern not observed among White participants. Future work should examine if being a military-dependent and a historically marginalized racial group member accounts for these findings. Such data may inform providers of youth with intersecting minority identities.

Fever of Unknown Origin in Adults.

Fever of unknown origin is defined as a clinically documented temperature of 101°F or higher on several occasions, coupled with an unrevealing diagnostic workup. The differential diagnosis is broad but is typically categorized as infection, malignancy, noninfectious inflammatory disease, or miscellaneous. Most cases in adults occur because of uncommon presentations of common diseases, and up to 75% of cases will resolve spontaneously without reaching a definitive diagnosis. In the absence of localizing signs and symptoms, the workup should begin with a comprehensive history and physical examination to help narrow potential etiologies. Initial testing should include an evaluation for infectious etiologies, malignancies, inflammatory diseases, and miscellaneous causes such as venous thromboembolism and thyroiditis. If erythrocyte sedimentation rate or C-reactive protein levels are elevated and a diagnosis has not been made after initial evaluation, 18F fluorodeoxyglucose positron emission tomography scan, with computed tomography, may be useful in reaching a diagnosis. If noninvasive diagnostic tests are unrevealing, then the invasive test of choice is a tissue biopsy because of the relatively high diagnostic yield. Depending on clinical indications, this may include liver, lymph node, temporal artery, skin, skin-muscle, or bone marrow biopsy. Empiric antimicrobial therapy has not been shown to be effective in the treatment of fever of unknown origin and therefore should be avoided except in patients who are neutropenic, immunocompromised, or critically ill.

Risk-based guidelines: Redefining management of abnormal cervical cancer screening results.

In making the 2019 guidelines for risk-based management of patients with abnormal cervical cancer screening tests and cancer precursors, the guidelines committee shifted from results-based to risk-based management recommendations, based on the patient's immediate and 5-year risks of grade 3 or higher cervical intraepithelial neoplasia (CIN 3+). The risk is determined by current and prior screening results (human papillomavirus infection, cytology testing) and the clinical history including age. An immediate 4% or higher risk of CIN 3+ was established as the dividing line between higher and lower risks, and the corresponding management recommendations. This article reviews the changes and their evidence base and discusses clinical implications of the revised guidelines.

Care of the College Student.

Approximately 19 million students attend college in the United States. Although they are generally healthy, about 20% of youth have special health care needs, including asthma, diabetes mellitus, and learning, mental health, and substance use disorders. Physicians can facilitate the transition of a youth to an adult model of health care by using structured processes to orient the youth to self-care before entry into college. Stimulant medications are effective for treatment of students with attention-deficit/hyperactivity disorder, but physicians should monitor for signs of drug diversion. Learning disorders may manifest with emotional or physical symptoms and are managed in a multidisciplinary fashion. Depression, anxiety, sleep problems, and posttraumatic stress and eating disorders are common in this population and can affect school performance. Screening and/or interventions for obesity, depression, anxiety, violence, nicotine use, and substance use are effective. Immunizations for influenza, human papillomavirus, meningococcus, and pertussis are crucial in this high-risk population. Lesbian, bisexual, gay, transgender, and queer students have unique health care needs.

Human Papillomavirus: Screening, Testing, and Prevention.

With more than 200 types identified, human papillomavirus (HPV) commonly causes infections of the skin and mucosa. HPV infection is the most common sexually transmitted infection in the United States. Although most HPV infections are transient and subclinical, some lead to clinical manifestations ranging from benign papillomas or warts to intraepithelial lesions. In some patients, persistent infection with high-risk mucosal types, especially HPV-16 and HPV-18, causes anal, cervical, oropharyngeal, penile, vaginal, and vulvar cancers. Most HPV-related cancers are believed to be caused by sexual spread of the virus. A history of multiple sex partners; initiation of sexual activity at an early age; not using barrier protection; other sexually transmitted infections, including HIV; an immunocompromised state; alcohol use; and smoking have been identified as risk factors for persistent HPV infections. Screening for HPV infection is effective in identifying precancerous lesions and allows for interventions that can prevent the development of cancer. Use of condoms and dental dams may decrease spread of the virus. Vaccination is the primary method of prevention. The nonavalent HPV vaccine is effective in preventing the development of high-grade precancerous cervical lesions in noninfected patients. Vaccination is ideally administered at 11 or 12 years of age, irrespective of the patient's sex. In general, a two-dose series is recommended if administered before 15 years of age; however, individuals who are immunocompromised require three doses.

Out-of-Hospital Birth.

Since the 1970s, most births in the United States have been planned to occur in a hospital. However, a small percentage of Americans choose to give birth outside of a hospital. The number of out-of-hospital births has increased, with one in every 61 U.S. births (1.64%) occurring out of the hospital in 2018. Out-of-hospital (or community) birth can be planned or unplanned. Of those that are planned, most occur at home and are assisted by midwives. Patients who choose a planned community birth do so for multiple reasons. International observational studies that demonstrate comparable outcomes between planned out-of-hospital and planned hospital birth may not be generalizable to the United States. Most U.S. studies have found statistically significant increases in perinatal mortality and neonatal morbidity for home birth compared with hospital birth. Conversely, planned community birth is associated with decreased odds of obstetric interventions, including cesarean delivery. Perinatal outcomes for community birth may be improved with appropriate selection of low-risk, vertex, singleton, term pregnancies in patients who have not had a previous cesarean delivery. A qualified, licensed maternal and newborn health professional who is integrated into a maternity health care system should attend all planned community births. Family physicians are uniquely poised to provide counseling to patients and their families about the risks and benefits associated with community birth, and they may be the first physicians to evaluate and treat newborns delivered outside of a hospital.

Weight-Based Teasing and Metabolic Syndrome Components among Adolescent Military Dependents at Risk for Adult Obesity.

Background: Among adults, weight stigma is associated with markers of poor cardiometabolic health. Although weight-based teasing (WBT) is common among youth with high body weight, few studies have examined its associations with cardiometabolic markers. Owing to unique stressors (e.g., parental deployment and frequent moves), military-dependent youth may be at particularly high risk for obesity, WBT, and poor cardiometabolic health. We, therefore, assessed associations between WBT and cardiometabolic health markers among adolescent military dependents presenting for a weight gain prevention trial. Methods: Participants underwent fasting phlebotomy; had fasting weight, height, and waist circumference measured; and completed assessments of WBT, anxiety, and loss-of-control eating. Multivariate analysis of covariance, adjusting for relevant covariates including demographics and body composition, was used to examine differences in metabolic syndrome (MetS) components (waist circumference, systolic and diastolic blood pressure, high-density lipoprotein cholesterol, triglycerides, and glucose) between youth reporting WBT and youth reporting no WBT. Bootstrapped models examined whether WBT mediated the relationship between BMIz and MetS components. Results: Data from 142 youth (57.7% female; 14.4 ± 1.6 years; 51.2% non-Hispanic White, 20.9% non-Hispanic Black; BMIz: 1.9 ± 0.4) were analyzed. WBT was not significantly associated with any MetS component. Relationships were observed between BMIz and all MetS components (except systolic blood pressure and glucose), although WBT did not significantly mediate these relationships (p's > 0.05). Conclusions: This study did not find support for a relationship between WBT and MetS components in adolescent military dependents at risk for adult obesity. Prospective research is needed to determine whether associations between WBT and adverse cardiometabolic outcomes emerge primarily in adulthood.

A Pilot Feasibility Study of Interpersonal Psychotherapy for the Prevention of Excess Weight Gain Among Adolescent Military-dependent Girls.

INTRODUCTION: Adolescent military-dependents face unique psychosocial stressors due to their parents' careers, suggesting they may be particularly vulnerable to excess weight gain and symptoms of depression and anxiety. Despite these risk factors, there is a lack of tested preventative interventions for these youths. Given the transient nature of military family deployments, research may be hindered due to difficulty in collecting long-term prospective outcome data, particularly measured height and weight. The primary aim of this study was to examine the feasibility and acceptability of collecting body mass index (BMI, kg/m2) outcome data up to 2 years following a randomized controlled pilot trial of an adapted interpersonal psychotherapy (IPT) program aimed at preventing excess weight gain and improving psychological functioning for adolescent military-dependents. In exploratory analyses, patterns in body composition over time were examined. MATERIALS AND METHODS: Twenty-seven adolescent military-dependent girls (baseline: Mage: 14.4 ± 1.6 years; MBMI: 30.7 ± 4.9 kg/m2; MBMI-z: 1.9 ± 0.4) participated in this study. After a baseline assessment, utilizing a computerized program to create a randomization string, girls were assigned to either an IPT or a health education (HE) program. Participants completed three follow-up visits (posttreatment, 1-year follow-up, and 2-year follow-up). Girls completed a Treatment Acceptability Questionnaire at posttreatment; at all time points, height and fasting weight were collected. For the primary aim, Fisher's exact tests examined the rate of obtained follow-up data and lost to follow-up status between the two groups, Mann-Whitney U tests examined the session attendance between groups, and treatment acceptability ratings were compared between the two groups at posttreatment using an independent samples t-test. For the exploratory aim, one-way analyses of covariance (ANCOVAs) examined the group differences in BMI at each time point, adjusting for baseline values, and paired samples t-tests examined the within-group differences at each time point relative to baseline. Using imputed data in the full intent-to-treat sample, mixed model ANCOVAs were conducted to examine the group differences over time. RESULTS: Across both groups, girls attended an average of 72.0% of sessions. At least partial data were collected at posttreatment, 1-year follow-up, and 2-year follow-up for 96.3%, 85.2%, and 74.1% of the participants, respectively. There were no significant group differences in follow-up data collection rates, follow-up status, number of sessions attended, or treatment acceptability. BMI-z stabilized across groups, and there were no group differences in BMI-z. In adjusted ANCOVA models with imputed data, no significant group-by-time effects emerged. CONCLUSIONS: For this randomized controlled prevention trial, long-term outcome data collection of measured BMI was possible in adolescent military-dependents and IPT was an acceptable and feasible intervention. An adequately powered trial is required to assess the efficacy of this intervention among military-dependents for obesity prevention and improvements in BMI.

Permanent change of station moves and disordered-eating attitudes and behaviors in prevention-seeking adolescent military-dependents.

OBJECTIVE: Military-dependent youth appear to be at greater risk for disordered-eating than their civilian counterparts. Permanent change of station moves (PCS-moves), typically occurring every 2-3 years, are commonly experienced by adolescent military-dependents. However, the links between PCS-moves and disordered-eating in this population have not been explored. We hypothesized that stress arising from PCS-moves may contribute to the development and/or exacerbation of disordered-eating. METHODS: One-hundred-forty-nine adolescent military-dependents with overweight or obesity (59.7% female; 46.3% non-Hispanic White; 14.4±1.5 years; BMI-z: 1.9±0.4) completed measures before commencing an adulthood obesity and binge-eating disorder prevention trial for adolescents at-risk for both conditions due to BMI percentile ≥85th and loss-of-control (LOC)-eating and/or elevated anxiety symptoms. Disordered-eating attitudes and LOC-eating were assessed by semi-structured interview, and emotional eating was self-reported. Adjusting for relevant covariates, multiple linear regressions examined the unique association of PCS-move frequency with disordered-eating attitudes and disinhibited-eating behaviors. RESULTS: PCS-move frequency was not significantly associated with either LOC-eating frequency (ß = 0.09, p = .27) or emotional eating (ß = -0.04, p = .62). However, PCS-move frequency was positively associated with disordered-eating attitudes (ß = 0.17, p = .04), which appeared to be primarily driven by shape concerns (ß = 0.21, p = .01). DISCUSSION: Findings indicate that frequency of PCS-moves is related to disordered-eating attitudes, but not behaviors. Longitudinal research is needed to understand if PCS-moves prospectively relate to the onset and/or exacerbation of disordered-eating, and the relevance of disordered-eating attitudes as opposed to disinhibited-eating behaviors.

Sex differences in metabolic syndrome components in adolescent military dependents at high-risk for adult obesity.

BACKGROUND: Metabolic syndrome in adolescence has been associated with adverse cardiometabolic outcomes in adulthood. Preliminary data suggest that boys may have worsened metabolic syndrome components compared to girls. Yet, little is known about the physical health of military dependents, a potentially at-risk population. OBJECTIVE: Examine sex differences in metabolic syndrome components in a sample of adolescent military dependents. METHODS: Participants were adolescents (N = 139; 14.4 ± 1.6 years; 45.3% male; 41.0% non-Hispanic White, 19.4% non-Hispanic Black; BMI-z: 1.9 ± 0.4) at-risk for adult obesity and binge-eating disorder due to an age- and sex-adjusted BMI ≥85th percentile and loss-of-control eating and/or elevated anxiety. A multivariate analysis of covariance was conducted to compare objectively measured metabolic syndrome components across boys and girls. Covariates were age, race, loss-of-control eating status, anxiety symptoms, and BMI-z. RESULTS: Metabolic syndrome components differed by sex (P = .01). Boys had higher systolic blood pressure (P = .049), lower high-density lipoprotein cholesterol (P = .01), and higher glucose (P = .001) than girls. Waist circumference, diastolic blood pressure, and triglycerides did not differ between boys and girls (P > .05). CONCLUSIONS: Future research should prospectively examine these relationships into adulthood. If the current findings are supported, prevention programs should consider targeting cardiometabolic health particularly among male adolescent military dependents.

Interventions to Improve Sexual and Reproductive Health in US Active Duty Military Service Members: A Systematic Review.

OBJECTIVE: To identify and describe behavioral interventions to promote sexual and reproductive health among US active duty military service members. DATA SOURCES: Systematic searches of PubMed, CINAHL, and PsychINFO (N = 1609 records). INCLUSION CRITERIA: English-language articles published between 1991 and 2018 and retrieved using search terms related to military service, interventions, and sexual and reproductive health. EXCLUSION CRITERIA: Articles excluded if not empirically based, not published in peer-reviewed journals, did not sample active duty US military personnel, and did not examine the effectiveness of specified preventive sexual or reproductive health intervention(s). DATA EXTRACTION: Teams of paired authors extracted study rationale; aims; design; setting; description of the intervention; measures; sample demographics; clinical, behavioral, and psychosocial outcomes; and conclusions. DATA SYNTHESIS: Given the heterogeneity of studies, narrative synthesis was performed. RESULTS: Fifteen articles met inclusion criteria: 10 focused on sexually transmitted infection (STI) acquisition and/or unintended pregnancy and 5 on sexual assault. Studies that assessed clinical outcomes found that interventions were associated with lower rates of STIs and/or unintended pregnancy. Significant effects were found on knowledge-related outcomes, while mixed effects were found on attitudes, intentions, and behaviors. CONCLUSIONS: Current evidence on the effectiveness of sexual and reproductive health interventions in the US military is limited in quality and scope. Promoting sexual and reproductive health in this population is critical to maintaining well-being among servicemembers, their families, and the communities surrounding military installations.

Primary Care Behavioral Health Training in Family Medicine Residencies: A Qualitative Study From a Large Health Care System.

BACKGROUND AND OBJECTIVES: Primary care behavioral health (PCBH) is a service delivery model of integrated care linked to a wide variety of positive patient and system outcomes. However, considerable challenges with provider training and attrition exist. While training for nonphysician behavioral scientists is well established, little is known about how to train physicians to work efficiently within integrated teams. METHODS: We conducted a case study analysis of family medicine residencies in the military health system using a series of 30 to 45-minute semistructured interviews. We conducted qualitative template analysis of these cases to chart programs' current educational processes related to PCBH. Thirteen individuals consisting of program directors, behavioral and nonbehavioral faculty, and residents across five programs participated in the study. RESULTS: Current educational processes included a variety of content on PCBH (eg, treatment for depression, clinical referral pathways, patient-centered communication), primarily using a mix of didactic and practice-based placements. Resource allocation was seen as a critical contributor to quality. There was variability in the degree to which integrated behavioral health providers were incorporated as residency faculty, such that programs where these specialists were more incorporated reported more intentional curriculum development and health care systems-level content. CONCLUSIONS: While behavioral health content was well represented in family medicine residency curriculum, the depth and integration of content was inconsistent. More intentional and integrated curriculum accompanied faculty development and integration of behavioral health faculty. Future research should evaluate if faculty development programs and faculty status of behavioral scientists results in different educational or health care outcomes.

Examination of the Interpersonal Model With Adolescent Military Dependents at High Risk for Adult Obesity.

OBJECTIVE: Adolescent military dependents may be at higher risk for psychosocial stressors and disordered eating compared with civilian youths, but the mechanisms underlying these risks are unclear. Interpersonal theory proposes that difficult relationships lead to negative affect, thereby promoting emotional eating, which has been linked to and predictive of disordered eating. The interpersonal model may have particular relevance for understanding disordered eating among adolescent military dependents, given the unique stressors related to their parents' careers. This study aimed to examine the premise of the interpersonal model (that negative emotions mediate the association between multiple aspects of social functioning and emotional eating) among a cohort of adolescent military dependents. METHODS: Military dependents (N=136; 56% female, mean±SD age=14±2 years, body mass index adjusted for age and sex [BMIz]=2.0±0.4) at risk for adult obesity and binge eating disorder, as indicated by reported loss-of-control eating and/or anxiety symptoms, were assessed prior to participation in a study of excess weight-gain prevention. Bootstrapped mediation analyses were conducted to examine depressive symptoms as a potential mediator of the relationship between social functioning and emotional eating. Analyses were adjusted for age, sex, race-ethnicity, BMIz, and presence of reported loss-of-control eating and anxiety. RESULTS: Depressive symptoms were a significant mediator of the relationship between multiple domains of social functioning, including loneliness, social adjustment related to family and friends, attachment to father and peers, and emotional eating (p<0.05). CONCLUSIONS: The interpersonal model may contribute to our understanding of excess weight gain and binge eating disorder among adolescent military dependents. Prospective data are needed to determine the utility of interpersonal theory in predicting treatment response and outcomes among this population.

Parental deployment and distress, and adolescent disordered eating in prevention-seeking military dependents.

OBJECTIVE: Parental military deployment can lead to stress in the family system due to concerns about the deployed service-member's safety and increased responsibilities for those not deployed. Parent-related stress can impact adolescent disordered eating. Given the important role that stress plays in disordered eating and obesity, it is crucial to understand the impacts of unique stressors to which vulnerable populations are exposed. METHOD: We studied 126 adolescent (14.3 ± 1.6 years; 59.5% girls; 44.4% non-Hispanic White; BMI-z, 1.91 ± .39) military dependents prior to entering an obesity and binge-eating disorder prevention trial. The Eating Disorder Examination was used to assess adolescent disordered eating. Parents self-reported their own distress and family deployment history that occurred during the adolescent's lifetime. RESULTS: Parental distress interacted with frequency of parental deployments such that for those with high parental distress, more frequent deployment was associated with greater adolescent shape and weight concerns (ß = .21, p = .012) and global eating pathology (ß = .18, p = .024). DISCUSSION: In this hypothesis-generating study, the combination of number of deployments and parental distress may be associated with disordered eating among adolescent military dependents seeking prevention of binge-eating disorder and adult obesity. If these preliminary findings are supported longitudinally, interventions to reduce parental stress related to deployment may be warranted to reduce disordered eating in adolescent dependents.

Associations between Family Weight-Based Teasing, Eating Pathology, and Psychosocial Functioning among Adolescent Military Dependents.

Weight-based teasing (WBT) by family members is commonly reported among youth and is associated with eating and mood-related psychopathology. Military dependents may be particularly vulnerable to family WBT and its sequelae due to factors associated with their parents' careers, such as weight and fitness standards and an emphasis on maintaining one's military appearance; however, no studies to date have examined family WBT and its associations within this population. Therefore, adolescent military dependents at-risk for adult obesity and binge-eating disorder were studied prior to entry in a weight gain prevention trial. Youth completed items from the Weight-Based Victimization Scale (to assess WBT by parents and/or siblings) and measures of psychosocial functioning, including the Beck Depression Inventory-II, The Rosenberg Self-Esteem Scale, and the Social Adjustment Scale. Eating pathology was assessed via the Eating Disorder Examination interview, and height and fasting weight were measured to calculate BMIz. Analyses of covariance, adjusting for relevant covariates including BMIz, were conducted to assess relationships between family WBT, eating pathology, and psychosocial functioning. Participants were 128 adolescent military dependents (mean age: 14.35 years old, 54% female, 42% non-Hispanic White, mean BMIz: 1.95). Nearly half the sample (47.7%) reported family WBT. Adjusting for covariates, including BMIz, family WBT was associated with greater eating pathology, poorer social functioning and self-esteem, and more depressive symptoms (ps ≤ 0.02). Among military dependents with overweight and obesity, family WBT is prevalent and may be linked with eating pathology and impaired psychosocial functioning; prospective research is needed to elucidate the temporal nature of these associations.